1184724924 NPI number — DR. DOUGLAS STEFANYK O. D.

Table of content: DR. DOUGLAS STEFANYK O. D. (NPI 1184724924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184724924 NPI number — DR. DOUGLAS STEFANYK O. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEFANYK
Provider First Name:
DOUGLAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O. D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184724924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8201 CAMINO MEDIA
Provider Second Line Business Mailing Address:
#202
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93311-2002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 LENNOX AVE
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-869-2010
Provider Business Practice Location Address Fax Number:
661-869-2708
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  13155 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 152WV0400X , with the licence number: 13155 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SD0131550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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