Provider Demographics
NPI:1619979630
Name:STEPHENS, TIMOTHY SHAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:SHAWN
Last Name:STEPHENS
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:PO BOX 6018
Mailing Address - Street 2:244 GRAND CENTRAL MALL
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1105
Mailing Address - Country:US
Mailing Address - Phone:304-485-1199
Mailing Address - Fax:304-428-8102
Practice Address - Street 1:244 GRAND CENTRAL MALL
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26101-1105
Practice Address - Country:US
Practice Address - Phone:304-485-1199
Practice Address - Fax:304-428-8102
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1004OS152W00000X
OH5261T2167152W00000X
TN2282152W00000X
KY1533DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001212Medicaid
WV3810001212Medicaid
WVU491792Medicare UPIN