Provider Demographics
NPI:1134192081
Name:POWELL, STEPHEN (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:POWELL
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 1:5033B TREXLER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-5810
Mailing Address - Country:US
Mailing Address - Phone:803-571-2161
Mailing Address - Fax:
Practice Address - Street 1:1230 AMELIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-5478
Practice Address - Country:US
Practice Address - Phone:803-531-0061
Practice Address - Fax:803-531-0095
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC246383Medicaid
SCT23982Medicare UPIN
SCT239820281Medicare ID - Type Unspecified