Provider Demographics
NPI:1235174889
Name:EBERSOLE, STEPHEN LEWIS (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LEWIS
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:168 EAST AVE
Mailing Address - Street 2:OPTOMERIC ASSOCIATES PA
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5626
Mailing Address - Country:US
Mailing Address - Phone:207-784-3564
Mailing Address - Fax:207-782-2541
Practice Address - Street 1:168 EAST AVE
Practice Address - Street 2:OPTOMETRIC ASSOCIATES
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-784-3564
Practice Address - Fax:207-782-2541
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME832TA152W00000X
MEOPT832TA6152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME313250099Medicaid
MEU72087Medicare UPIN
ME313250099Medicaid