Provider Demographics
NPI:1073205910
Name:MONGOLD, STEPHANIE (LDO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MONGOLD
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4266 LINKS DR APT 104
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5663
Mailing Address - Country:US
Mailing Address - Phone:479-601-1944
Mailing Address - Fax:
Practice Address - Street 1:4870 ELM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-3749
Practice Address - Country:US
Practice Address - Phone:479-306-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL-140942156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician