Provider Demographics
NPI:1871666057
Name:BURRIS, STEPHANIE ANNE (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:BURRIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-2548
Mailing Address - Country:US
Mailing Address - Phone:805-569-2318
Mailing Address - Fax:805-569-0230
Practice Address - Street 1:1629 STATE ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-2548
Practice Address - Country:US
Practice Address - Phone:805-569-2318
Practice Address - Fax:805-569-0230
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10928T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU74951Medicare UPIN
CAWOP10928AMedicare PIN