Healthcare Provider Details

I. General information

NPI: 1285670588
Provider Name (Legal Business Name): VENESSA LYNN STINVIL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SAGAMORE LN
DIX HILLS NY
11746-6014
US

IV. Provider business mailing address

4 SAGAMORE LN
DIX HILLS NY
11746-6014
US

V. Phone/Fax

Practice location:
  • Phone: 631-836-9100
  • Fax: 631-253-4101
Mailing address:
  • Phone: 631-836-9100
  • Fax: 631-253-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004477A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003729
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPOP37
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005425
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: