Provider Demographics
NPI:1083828545
Name:LANDRETH, STEVEN R (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:LANDRETH
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 1:1655 MCFARLAND BLVD N
Mailing Address - Street 2:SUITE 127
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2212
Mailing Address - Country:US
Mailing Address - Phone:205-758-0242
Mailing Address - Fax:
Practice Address - Street 1:3519 WATERMELON RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5174
Practice Address - Country:US
Practice Address - Phone:205-758-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS914TA467152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051554102Medicaid
AL51500676OtherBCBS OF AL
AL051554102Medicaid
ALU76492Medicare UPIN