Provider Demographics
NPI:1245924380
Name:ATWELL, STEPHEN CHARLES (LDO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHARLES
Last Name:ATWELL
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N GALLERIA DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3008
Mailing Address - Country:US
Mailing Address - Phone:845-692-5145
Mailing Address - Fax:845-692-5141
Practice Address - Street 1:300 N GALLERIA DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3008
Practice Address - Country:US
Practice Address - Phone:845-692-5145
Practice Address - Fax:845-692-5141
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010160156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician