Basic Information
| Provider Information | |||||||||
| NPI: | 1891817573 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMY M. STEPHENS, O.D., P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EYE SAVERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1480 TIMBERLANE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323121713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508942332 | ||||||||
| FaxNumber: | 8506688625 | ||||||||
| Practice Location | |||||||||
| Address1: | 15196 US HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317574820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292284770 | ||||||||
| FaxNumber: | 2292259060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2292284770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 001621 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 00825833A | 05 | GA | MEDICAID | 07566 | 01 | GA | SPECTERA | OTHER | 44253 | 01 | GA | AVESIS-GROUP | OTHER | 92033 | 01 | GA | AVESIS MEDICAID | OTHER |