Provider Demographics
NPI:1457346330
Name:STELLHORN, FREDERICK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:STELLHORN
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 1:140 N FREMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4725
Mailing Address - Country:US
Mailing Address - Phone:209-823-3151
Mailing Address - Fax:209-823-9712
Practice Address - Street 1:140 N FREMONT ST
Practice Address - Street 2:SUITE A
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4725
Practice Address - Country:US
Practice Address - Phone:209-823-3151
Practice Address - Fax:209-823-9712
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2010-07-30
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CA5215TPL152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
CA5215 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052150Medicaid
CAT09907Medicare UPIN
CASD0052150Medicare ID - Type Unspecified
CA0761140001Medicare NSC