Provider Demographics
NPI:1235131376
Name:TOM, STEPHANIE (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 MOWRY AVE STE B5
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1724
Mailing Address - Country:US
Mailing Address - Phone:510-742-1004
Mailing Address - Fax:510-742-1013
Practice Address - Street 1:505 J DAVIS ARMISTEAD BLDG
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-1921
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5599TG152W00000X
CA12087T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037184101Medicaid
TX80468EMedicare ID - Type Unspecified
TXU81425Medicare UPIN