Provider Demographics
NPI:1619038858
Name:PARDRIDGE, STEPHEN WESLEY (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WESLEY
Last Name:PARDRIDGE
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 1:2807 MARKET ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-4535
Mailing Address - Country:US
Mailing Address - Phone:717-737-7717
Mailing Address - Fax:717-737-7718
Practice Address - Street 1:2807 MARKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4535
Practice Address - Country:US
Practice Address - Phone:717-737-7717
Practice Address - Fax:717-737-7718
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOETO8728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001940672-0001Medicaid
PA090624Medicare ID - Type Unspecified
PA001940672-0001Medicaid