Provider Demographics
NPI:1194851030
Name:AVERITT, STEPHEN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARK
Last Name:AVERITT
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 1:3900 MORSE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3016
Mailing Address - Country:US
Mailing Address - Phone:614-804-7147
Mailing Address - Fax:
Practice Address - Street 1:3900 MORSE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3016
Practice Address - Country:US
Practice Address - Phone:614-804-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4437T1161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2465872Medicaid
OH2465872Medicaid
OH4012201Medicare ID - Type Unspecified'PIN NUMBER'