Basic Information
| Provider Information | |||||||||
| NPI: | 1982638508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4521 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066600191 | ||||||||
| FaxNumber: | 7065968388 | ||||||||
| Practice Location | |||||||||
| Address1: | 4521 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066600191 | ||||||||
| FaxNumber: | 7065968388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001916 | GA | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | OPT001916 | GA | Y | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WX0102X | OPT001916 | GA | N | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152WP0200X | OPT001916 | GA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WS0006X | OPT001916 | GA | N | Eye and Vision Services Providers | Optometrist | Sports Vision |
ID Information
| ID | Type | State | Issuer | Description | 2536269 | 01 | GA | UNITED HEALTHCARE | OTHER | OPT001916 | 01 | GA | LICENSE | OTHER | DEA | 01 | GA | MS0878605 | OTHER | 255363535B | 05 | GA | MEDICAID |