=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770663866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHEN P CASSIS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 10/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 49TH ST SE STE A
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-925-3937
-----------------------------------------------------
Fax | 304-925-4336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 49TH ST SE STE A
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-925-3937
-----------------------------------------------------
Fax | 304-925-4336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MELISA CASSIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-925-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2026-IOD1
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 12950
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------