Provider Demographics
NPI:1336231588
Name:SHIROLA, STEPHEN JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:SHIROLA
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 1:11673 PONDVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316
Mailing Address - Country:US
Mailing Address - Phone:763-422-9209
Mailing Address - Fax:
Practice Address - Street 1:6268 BOONE AVE NORTH
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428
Practice Address - Country:US
Practice Address - Phone:763-257-0344
Practice Address - Fax:763-257-0346
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39352Medicare UPIN