Provider Demographics
NPI:1073609913
Name:SULYI, STEPHEN CARL (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CARL
Last Name:SULYI
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 1:118 CHIMNEY RDG
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-4006
Mailing Address - Country:US
Mailing Address - Phone:864-884-7432
Mailing Address - Fax:864-688-2307
Practice Address - Street 1:118 CHIMNEY RDG
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-4006
Practice Address - Country:US
Practice Address - Phone:864-884-7432
Practice Address - Fax:864-688-2307
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002332152W00000X
SC1437152W00000X
OH6524152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0212124Medicaid