Healthcare Provider Details

I. General information

NPI: 1619045366
Provider Name (Legal Business Name): STEPHEN AUSTIN HOVERMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 SUNRISE BLVD SUNRISE MALL
CITRUS HEIGHTS CA
95610
US

IV. Provider business mailing address

3910 VILLA CT
FAIR OAKS CA
95628-7422
US

V. Phone/Fax

Practice location:
  • Phone: 916-961-0395
  • Fax:
Mailing address:
  • Phone: 916-692-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9138 T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: