Provider Demographics
NPI:1336295559
Name:SOUTHERLIN, STEPHANIE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:SOUTHERLIN
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 1:2131 WOODRUFF RD
Mailing Address - Street 2:SUITE 2100 #282
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5950
Mailing Address - Country:US
Mailing Address - Phone:864-458-8633
Mailing Address - Fax:
Practice Address - Street 1:2084 WOODRUFF RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-458-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1273152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA07739663Medicare PIN