Provider Demographics
NPI:1215984224
Name:SCHROEDER, JUSTIN MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:SCHROEDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 BRAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3159
Mailing Address - Country:US
Mailing Address - Phone:731-285-5411
Mailing Address - Fax:731-285-8481
Practice Address - Street 1:400 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-3937
Practice Address - Fax:573-333-3938
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2451152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN150674OtherBETTER HEALTH
TN3722767Medicaid
TN4067790OtherBLUE CROSS BLUE SHIELD TN
TN0797303OtherCIGNA
MO000025643Medicare PIN
TN0797303OtherCIGNA
TNU86585Medicare UPIN
MOP00478733Medicare PIN
TN3722767Medicaid