Provider Demographics
NPI:1922112226
Name:FITZGERALD, STEPHANIE ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ELAINE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:ELAINE
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2440 ANNALEE AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2210
Mailing Address - Country:US
Mailing Address - Phone:314-968-6432
Mailing Address - Fax:
Practice Address - Street 1:100 THF BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1123
Practice Address - Country:US
Practice Address - Phone:636-536-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02884152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU02619Medicare UPIN