MEDICARE: STEPHANIE LYNN CULLINAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3051	TN
2	152W00000X	Optometrist	862	MS
3	152W00000X	Optometrist	2013023063	MO

General Provider Information

NPI Number	:	1275898173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN CULLINAN O.D.

Provider Business Mailing Address
First Line	:	40 E NORTH ST
Second Line	:
City	:	EUREKA
State	:	MO
Zip	:	63025-1205
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-938-2650

Provider Business Practice Location Address
First Line	:	3122 S GRAND
Second Line	:
City	:	ST. LOUIS
State	:	MO
Zip	:	63118
Country	:	US
Telephone Number	:	314-450-7313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2012
Last Update Date	:	11/19/2014

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