MEDICARE: DR. MARILOU V STEPHAN 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	MN1770	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ST794518	OTHER	MN	CLARITY VISION
2	22-20201	OTHER	MN	MEDICA/UNITED HEALTH CARE
3	23750	OTHER	MN	AMERICA'S PPO
4	12083	OTHER	MN	COLE MANAGED VISION CARE
5	MN 1770	OTHER	MN	EYEMED VISION CARE
6	85601ST	OTHER	MN	BCBS OF MN

General Provider Information

NPI Number	:	1558367136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARILOU V STEPHAN O.D.

Provider Business Mailing Address
First Line	:	3333 HAZELTON RD
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-4204
Country	:	US
Telephone Number	:	952-926-6149
Fax Number	:	952-926-2729

Provider Business Practice Location Address
First Line	:	3333 HAZELTON RD
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-4204
Country	:	US
Telephone Number	:	952-926-6149
Fax Number	:	952-926-2729

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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