Provider Demographics
NPI:1568803419
Name:LESAGE, STEPHANIE KIM (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KIM
Last Name:LESAGE
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 1:6336 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6336 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214
Practice Address - Country:US
Practice Address - Phone:713-732-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1658-692T152W00000X
MA5043152W00000X
TX8268-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA01102701Medicaid
LA2342797Medicaid
LA312442YH3UMedicare PIN