Basic Information
| Provider Information | |||||||||
| NPI: | 1508270422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 LAKE FOREST DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452423744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135693741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 CEI DR | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452425664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139845133 | ||||||||
| FaxNumber: | 5139844240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 05/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 4301105441 | MI | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 293423 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 35138884 | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0400518 | 05 | OH | MEDICAID |