Provider Demographics
NPI:1013965367
Name:GOGGIN, STEPHANIE R (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:R
Last Name:GOGGIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6620 CENTER GROVE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2802
Mailing Address - Country:US
Mailing Address - Phone:618-659-1900
Mailing Address - Fax:
Practice Address - Street 1:6620 CENTER GROVE ROAD
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2802
Practice Address - Country:US
Practice Address - Phone:618-659-1900
Practice Address - Fax:618-659-1901
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410043847OtherRAILROAD MEDICARE - SFLD
IL410043848OtherRAILROAD MEDICARE - HILLS
IL046009281Medicaid
IL594030Medicare PIN
IL410043847OtherRAILROAD MEDICARE - SFLD
ILU81742Medicare UPIN