Provider Demographics
NPI:1043376528
Name:DEAN, STEPHEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:DEAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 E HOSPITALITY LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2813
Mailing Address - Country:US
Mailing Address - Phone:909-478-5554
Mailing Address - Fax:909-478-0393
Practice Address - Street 1:1099 E HOSPITALITY LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2813
Practice Address - Country:US
Practice Address - Phone:909-478-5554
Practice Address - Fax:909-478-0393
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8072T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0080720Medicaid
CASD0080720Medicaid