Provider Demographics
NPI:1104832112
Name:WHEELER, STEPHEN KING (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KING
Last Name:WHEELER
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 1:322 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2233
Mailing Address - Country:US
Mailing Address - Phone:937-376-4055
Mailing Address - Fax:937-376-3969
Practice Address - Street 1:322 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2233
Practice Address - Country:US
Practice Address - Phone:937-376-4055
Practice Address - Fax:937-376-3969
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2630139Medicaid
OH2630166Medicaid
OH0245425Medicaid
OH2630139Medicaid
9367331Medicare PIN