Healthcare Provider Details

I. General information

NPI: 1962439588
Provider Name (Legal Business Name): DEWANNA K STAUP O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6838 HIGHWAY 431 S SUITE A
OWENS CROSS ROADS AL
35763-7200
US

IV. Provider business mailing address

6838 HIGHWAY 431 S SUITE A
OWENS CROSS ROADS AL
35763-7200
US

V. Phone/Fax

Practice location:
  • Phone: 256-534-3900
  • Fax:
Mailing address:
  • Phone: 256-534-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-782-TA-246
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: