Provider Demographics
NPI:1225219611
Name:DR. T. SHAWN STEPHENS
Entity Type:Organization
Organization Name:DR. T. SHAWN STEPHENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-485-1199
Mailing Address - Street 1:244 GRAND CENTRAL MALL
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1105
Mailing Address - Country:US
Mailing Address - Phone:304-485-1199
Mailing Address - Fax:304-428-8102
Practice Address - Street 1:244 GRAND CENTRAL MALL
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26101-1105
Practice Address - Country:US
Practice Address - Phone:304-485-1199
Practice Address - Fax:304-428-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1004-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001212Medicaid
WV3810001212Medicaid
WV9327721Medicare PIN
WVU91792Medicare UPIN