Provider Demographics
NPI:1558367136
Name:STEPHAN, MARILOU V (OD)
Entity Type:Individual
Prefix:DR
First Name:MARILOU
Middle Name:V
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3333 HAZELTON RD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4204
Mailing Address - Country:US
Mailing Address - Phone:952-926-6149
Mailing Address - Fax:952-926-2729
Practice Address - Street 1:3333 HAZELTON RD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4204
Practice Address - Country:US
Practice Address - Phone:952-926-6149
Practice Address - Fax:952-926-2729
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNST794518OtherCLARITY VISION
MN22-20201OtherMEDICA/UNITED HEALTH CARE
MN23750OtherAMERICA'S PPO
MN12083OtherCOLE MANAGED VISION CARE
MNMN 1770OtherEYEMED VISION CARE
MN85601STOtherBCBS OF MN
MNST794518OtherCLARITY VISION