Healthcare Provider Details

I. General information

NPI: 1497896435
Provider Name (Legal Business Name): STEPHANIE KU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 05/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E 64TH ST SUITE 101
NEW YORK NY
10065-6635
US

IV. Provider business mailing address

205 E 64TH ST SUITE 101
NEW YORK NY
10065-6635
US

V. Phone/Fax

Practice location:
  • Phone: 212-888-4100
  • Fax: 212-888-4111
Mailing address:
  • Phone: 212-888-4100
  • Fax: 212-888-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007207
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number13036T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: