Provider Demographics
NPI:1114079753
Name:STOFENBERG, ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:STOFENBERG
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 1:19 ABBOT RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2322
Mailing Address - Country:US
Mailing Address - Phone:631-979-8313
Mailing Address - Fax:
Practice Address - Street 1:881 BROADWAY MALL
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2712
Practice Address - Country:US
Practice Address - Phone:516-938-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY3501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00338725Medicaid
NYA400007038Medicare UPIN