Provider Demographics
NPI:1134501091
Name:POWELL, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E MARKET ST
Mailing Address - Street 2:103
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5214
Mailing Address - Country:US
Mailing Address - Phone:434-995-2240
Mailing Address - Fax:434-995-2241
Practice Address - Street 1:410 E MARKET ST
Practice Address - Street 2:103
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5214
Practice Address - Country:US
Practice Address - Phone:434-995-2240
Practice Address - Fax:434-995-2241
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101002515156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician