Provider Demographics
NPI:1609853878
Name:HARRELL, STEPHEN W (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
Last Name:HARRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2104
Mailing Address - Country:US
Mailing Address - Phone:336-835-2244
Mailing Address - Fax:336-835-9961
Practice Address - Street 1:1816 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2104
Practice Address - Country:US
Practice Address - Phone:336-835-2244
Practice Address - Fax:336-835-9961
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1293152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCT81630Medicare UPIN
NC246622Medicare ID - Type Unspecified
NC0549160001Medicare NSC