Provider Demographics
NPI:1063449817
Name:SUMNER, STACEY D (OD)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:D
Last Name:SUMNER
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 1:14607 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3617
Mailing Address - Country:US
Mailing Address - Phone:818-789-3311
Mailing Address - Fax:818-789-1047
Practice Address - Street 1:14607 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3617
Practice Address - Country:US
Practice Address - Phone:818-789-3311
Practice Address - Fax:818-789-1047
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9553T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU25726Medicare UPIN
CA0852280001Medicare NSC
CAOP9553Medicare PIN