Provider Demographics
NPI:1043394406
Name:KROK, STEPHANIE (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KROK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PACIFIC AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-7505
Mailing Address - Country:US
Mailing Address - Phone:831-466-3937
Mailing Address - Fax:831-466-3421
Practice Address - Street 1:1101 PACIFIC AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-7505
Practice Address - Country:US
Practice Address - Phone:831-466-3937
Practice Address - Fax:831-466-3421
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10494-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104941Medicare PIN
CASD0104940Medicare ID - Type Unspecified
CAU75962Medicare UPIN