Provider Demographics
NPI:1386644151
Name:SUSSMANE, SHAWN T (OD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:T
Last Name:SUSSMANE
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:PO BOX 100284
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0284
Mailing Address - Country:US
Mailing Address - Phone:352-273-8778
Mailing Address - Fax:352-273-7402
Practice Address - Street 1:1124 E WEISGARBER RD STE 104
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2686
Practice Address - Country:US
Practice Address - Phone:865-584-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2032152W00000X
FLOPC6391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4025051OtherBCBS
TN3944150Medicaid
U75387Medicare UPIN
TN3944150Medicaid