Provider Demographics
NPI:1306412408
Name:PARKER, STEPHANIE MAE (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MAE
Last Name:PARKER
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 1:4948 POTOMAC SQUARE PL UNIT 2
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-5802
Mailing Address - Country:US
Mailing Address - Phone:810-338-9254
Mailing Address - Fax:
Practice Address - Street 1:4281 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3997
Practice Address - Country:US
Practice Address - Phone:810-385-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-29
Last Update Date:2021-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist