Provider Demographics
NPI:1962439588
Name:STAUP, DEWANNA K (OD)
Entity Type:Individual
Prefix:DR
First Name:DEWANNA
Middle Name:K
Last Name:STAUP
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 1:6838 HIGHWAY 431 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-7200
Mailing Address - Country:US
Mailing Address - Phone:256-534-3900
Mailing Address - Fax:
Practice Address - Street 1:6838 HIGHWAY 431 S
Practice Address - Street 2:SUITE A
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-7200
Practice Address - Country:US
Practice Address - Phone:256-534-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-782-TA-246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000058516Medicaid
ALU44234Medicare UPIN
AL58516Medicare ID - Type Unspecified