Provider Demographics
NPI:1154322287
Name:STEPHEN L LAURITSEN OD PA
Entity Type:Organization
Organization Name:STEPHEN L LAURITSEN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LAURITSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-781-7277
Mailing Address - Street 1:204 US ROUTE 1
Mailing Address - Street 2:CARRIAGE HOUSE SQUARE
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1342
Mailing Address - Country:US
Mailing Address - Phone:207-781-7277
Mailing Address - Fax:207-781-7277
Practice Address - Street 1:204 US ROUTE 1
Practice Address - Street 2:CARRIAGE HOUSE SQUARE
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1342
Practice Address - Country:US
Practice Address - Phone:207-781-7277
Practice Address - Fax:207-781-7277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME782-TA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM6391Medicare ID - Type Unspecified