Provider Demographics
NPI:1972659050
Name:SASALA, STEPHEN FREDERICK (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:FREDERICK
Last Name:SASALA
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 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:6835 PEARL RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HTS
Practice Address - State:OH
Practice Address - Zip Code:44130
Practice Address - Country:US
Practice Address - Phone:440-884-4725
Practice Address - Fax:440-884-4752
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH40461834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U40461Medicare UPIN