=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922112226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE ELAINE FITZGERALD OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 02/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 THF BLVD
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-536-4609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2440 ANNALEE AVE
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63144-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-968-6432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T02884
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------