Provider Demographics
NPI:1255350740
Name:VAN VOORST, STACIE ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:ANNE
Last Name:VAN VOORST
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:STACIE
Other - Middle Name:ANNE
Other - Last Name:HOUGHTALEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:110 NORTH PRESTON ROAD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8794
Mailing Address - Country:US
Mailing Address - Phone:972-347-2004
Mailing Address - Fax:972-347-3847
Practice Address - Street 1:110 NORTH PRESTON ROAD
Practice Address - Street 2:SUITE 30
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8794
Practice Address - Country:US
Practice Address - Phone:972-347-2004
Practice Address - Fax:972-347-3847
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6554TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1942Medicare ID - Type UnspecifiedPROVIDER NUMBER
TXV07813Medicare UPIN