Provider Demographics
NPI:1679630867
Name:CASSIDY, STEPHAN L (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:L
Last Name:CASSIDY
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 1:450 NW GILMAN BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2483
Mailing Address - Country:US
Mailing Address - Phone:425-392-8756
Mailing Address - Fax:425-391-8631
Practice Address - Street 1:450 NW GILMAN BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2483
Practice Address - Country:US
Practice Address - Phone:425-392-8756
Practice Address - Fax:425-391-8631
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028686Medicaid
WAU60209Medicare UPIN
WAG8864089Medicare PIN