Provider Demographics
NPI:1518004134
Name:KIRSCHBAUM, STEPHANIE JO (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JO
Last Name:KIRSCHBAUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:JO
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:360 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5088
Mailing Address - Country:US
Mailing Address - Phone:530-273-3190
Mailing Address - Fax:530-273-5541
Practice Address - Street 1:360 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5088
Practice Address - Country:US
Practice Address - Phone:530-273-3190
Practice Address - Fax:530-273-5541
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8763T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49206YOtherGROUP MEDICAID PIN
CP5473OtherGROUP RR MEDICARE PIN
CP5473OtherGROUP RR MEDICARE PIN