Provider Demographics
NPI:1972507317
Name:STEPHENS, LOPASTEEDA DEROSA (OD)
Entity Type:Individual
Prefix:
First Name:LOPASTEEDA
Middle Name:DEROSA
Last Name:STEPHENS
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37111-0308
Mailing Address - Country:US
Mailing Address - Phone:931-473-6865
Mailing Address - Fax:931-473-5870
Practice Address - Street 1:915 N CHANCERY ST
Practice Address - Street 2:STE 120
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1575
Practice Address - Country:US
Practice Address - Phone:931-473-6865
Practice Address - Fax:931-473-5269
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3598018Medicaid
TN1013490001Medicare NSC
TN3598018Medicaid
TNU19812Medicare UPIN