Provider Demographics
NPI:1912039595
Name:SUMMEROW, STEPHEN D (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:SUMMEROW
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 1:216 CORDER RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3604
Mailing Address - Country:US
Mailing Address - Phone:478-322-4107
Mailing Address - Fax:478-922-9020
Practice Address - Street 1:216 CORDER RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-923-5872
Practice Address - Fax:478-922-9020
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000764189YMedicaid
GA00764189RMedicaid
GA67923Medicare UPIN