Provider Demographics
NPI:1124020375
Name:STEPHEN A UPDEGRAFF MD PA
Entity Type:Organization
Organization Name:STEPHEN A UPDEGRAFF MD PA
Other - Org Name:UPDEGRAFF VISION LASER AND SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:UPDEGRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-822-4287
Mailing Address - Street 1:1601 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-1926
Mailing Address - Country:US
Mailing Address - Phone:727-822-4287
Mailing Address - Fax:727-822-1086
Practice Address - Street 1:1601 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1926
Practice Address - Country:US
Practice Address - Phone:727-822-4287
Practice Address - Fax:727-822-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1171207W00000X
FLME67224332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4403500001Medicare NSC
FL40894Medicare ID - Type Unspecified