Provider Demographics
NPI:1770586521
Name:RAE, STEVEN T (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:T
Last Name:RAE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0444
Mailing Address - Country:US
Mailing Address - Phone:870-424-4900
Mailing Address - Fax:870-741-6331
Practice Address - Street 1:105 SAWGRASS PT
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3072
Practice Address - Country:US
Practice Address - Phone:870-741-1910
Practice Address - Fax:870-741-6331
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128334722Medicaid
AR48949Medicare ID - Type Unspecified