Provider Demographics
NPI:1932131331
Name:STUPP, ELLIOTT (OD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:STUPP
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 1:6248 WEYMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-2763
Mailing Address - Country:US
Mailing Address - Phone:941-889-6381
Mailing Address - Fax:
Practice Address - Street 1:4171 S TAMIAMI TR
Practice Address - Street 2:#34
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-2932
Practice Address - Country:US
Practice Address - Phone:941-223-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621028700Medicaid
FLU4122Medicare PIN
FLV03430Medicare UPIN