MEDICARE: STEPHANIE OH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1085	NV
2	390200000X	Student in an Organized Health Care Education/Training Program
3	152W00000X	Optometrist	35822	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871155168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE OH OD

Provider Business Mailing Address
First Line	:	3855 BROAD ST STE B
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7109
Country	:	US
Telephone Number	:	805-545-8100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3855 BROAD ST STE B
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7109
Country	:	US
Telephone Number	:	805-545-8100
Fax Number	:	805-548-8785

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	02/28/2025

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Directions to “ STEPHANIE OH OD” Practice Location

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