Provider Demographics
NPI:1225195431
Name:STEPHAN CASSIDY OD PS
Entity Type:Organization
Organization Name:STEPHAN CASSIDY OD PS
Other - Org Name:ISSAQUAH VISION SOURCE, PS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-392-8756
Mailing Address - Street 1:450 NW GILMAN BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2483
Mailing Address - Country:US
Mailing Address - Phone:425-392-8756
Mailing Address - Fax:425-391-8631
Practice Address - Street 1:450 NW GILMAN BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2483
Practice Address - Country:US
Practice Address - Phone:425-392-8756
Practice Address - Fax:425-391-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2081305Medicaid
WA6057100001Medicare NSC
WA2081305Medicaid