Provider Demographics
NPI:1639292865
Name:STEFANI, MARK ANDREW (OD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:STEFANI
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 1:32925 GROESBECK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026
Mailing Address - Country:US
Mailing Address - Phone:586-293-8888
Mailing Address - Fax:586-296-0726
Practice Address - Street 1:32925 GROESBECK HIGHWAY
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026
Practice Address - Country:US
Practice Address - Phone:586-293-8888
Practice Address - Fax:586-296-0726
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003690152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
110955OtherEYEMED
MI3404800Medicaid
900E06513OtherBCBS
0552080001Medicare ID - Type Unspecified
MIMO91340Medicare PIN
110955OtherEYEMED