Provider Demographics
NPI:1295213502
Name:KOSTAKIS, STEPHANIE A (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:A
Last Name:KOSTAKIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:STEFANIA
Other - Middle Name:A
Other - Last Name:KOSTAKIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3061 MARLO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1310
Mailing Address - Country:US
Mailing Address - Phone:727-215-0103
Mailing Address - Fax:
Practice Address - Street 1:8 SOUTHWOODS BLVD STE 8
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2554
Practice Address - Country:US
Practice Address - Phone:800-983-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008680-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty