Basic Information
Provider Information | |||||||||
NPI: | 1598825184 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEPHENS | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1950 OLD GALLOWS RD | ||||||||
Address2: | STE 520 | ||||||||
City: | VIENNA | ||||||||
State: | VA | ||||||||
PostalCode: | 221823970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508934005 | ||||||||
FaxNumber: | 8508945462 | ||||||||
Practice Location | |||||||||
Address1: | 15196 US HIGHWAY 19 S | ||||||||
Address2: |   | ||||||||
City: | THOMASVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 317574820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292284770 | ||||||||
FaxNumber: | 2292259060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 02/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3179 | FL | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 001621 | GA | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 620388400 | 05 | FL |   | MEDICAID | 20842 | 01 | FL | BLUR CROSS BLUE SHIELD | OTHER | 410037564 | 01 | FL | RAILROAD MEDICARE | OTHER | 00825833A | 05 | GA |   | MEDICAID |