Provider Demographics
NPI:1265817993
Name:GENDAL, STEPHANIE (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GENDAL
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 1:553 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-3048
Mailing Address - Country:US
Mailing Address - Phone:954-873-9833
Mailing Address - Fax:
Practice Address - Street 1:61 WESTFARMS MALL
Practice Address - Street 2:D111
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2631
Practice Address - Country:US
Practice Address - Phone:954-873-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist