Provider Demographics
NPI:1811178395
Name:INGMAN, STEPHEN JOHN (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:INGMAN
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 1:11879 KEMPER RD
Mailing Address - Street 2:STE 6
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9021
Mailing Address - Country:US
Mailing Address - Phone:530-823-5411
Mailing Address - Fax:530-823-5380
Practice Address - Street 1:11879 KEMPER RD
Practice Address - Street 2:STE 6
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9021
Practice Address - Country:US
Practice Address - Phone:530-823-5411
Practice Address - Fax:530-823-5380
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6466T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2820714Medicaid
CAP00742598OtherRAILROAD MEDICARE
CA0578460001Medicare NSC
CADD322YMedicare PIN
CA2820714Medicaid