Provider Demographics
NPI:1154475671
Name:STOREY, STEPHEN JUDD (O,D)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JUDD
Last Name:STOREY
Suffix:
Gender:M
Credentials:O,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3207
Mailing Address - Country:US
Mailing Address - Phone:815-756-6388
Mailing Address - Fax:815-756-4861
Practice Address - Street 1:121 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3207
Practice Address - Country:US
Practice Address - Phone:815-756-6388
Practice Address - Fax:815-756-4861
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007333Medicaid
ILT38374Medicare UPIN
IL046007333Medicaid
IL0648450001Medicare NSC