Provider Demographics
NPI:1457336927
Name:STEPHENS, BRYAN KEITH (OD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:KEITH
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1722 BASHOR RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1302
Mailing Address - Country:US
Mailing Address - Phone:574-533-4141
Mailing Address - Fax:574-534-2278
Practice Address - Street 1:1722 BASHOR RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1302
Practice Address - Country:US
Practice Address - Phone:574-533-4141
Practice Address - Fax:574-534-2278
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1800-2579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU33155Medicare UPIN