Basic Information
| Provider Information | |||||||||
| NPI: | 1922396076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOO | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 LAKE HAVASU AVE S | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864039368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286801144 | ||||||||
| FaxNumber: | 9286808639 | ||||||||
| Practice Location | |||||||||
| Address1: | 383 LAKE HAVASU AVE S | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864039368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286801144 | ||||||||
| FaxNumber: | 9286808639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2011 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1812 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2011019156 | MO | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 2011019156 | MO | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 1922396076 | 05 | MO | MEDICAID |