Provider Demographics
NPI:1326005869
Name:STEFANIDIS, NICOLETTA J (OD)
Entity Type:Individual
Prefix:
First Name:NICOLETTA
Middle Name:J
Last Name:STEFANIDIS
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 1:24401 CALLE DE LA LOUISA
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3623
Mailing Address - Country:US
Mailing Address - Phone:949-951-2020
Mailing Address - Fax:949-951-9244
Practice Address - Street 1:24401 CALLE DE LA LOUISA
Practice Address - Street 2:SUITE 300
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3623
Practice Address - Country:US
Practice Address - Phone:949-951-2020
Practice Address - Fax:949-951-9244
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9367TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP9367DMedicare ID - Type Unspecified
CAU54005Medicare UPIN