Provider Demographics
NPI:1619072287
Name:FARRIS, STEPHEN JEFFREY (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JEFFREY
Last Name:FARRIS
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 1:420 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4846
Mailing Address - Country:US
Mailing Address - Phone:208-459-2020
Mailing Address - Fax:208-459-2034
Practice Address - Street 1:121 E MERCED ST
Practice Address - Street 2:SUITE A
Practice Address - City:FOWLER
Practice Address - State:CA
Practice Address - Zip Code:93625-2312
Practice Address - Country:US
Practice Address - Phone:559-316-7053
Practice Address - Fax:559-316-7054
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12422T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124220Medicare PIN