Provider Demographics
NPI:1821013707
Name:OMON, STACY REI (OD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:REI
Last Name:OMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5904
Mailing Address - Country:US
Mailing Address - Phone:559-585-3937
Mailing Address - Fax:559-582-3645
Practice Address - Street 1:1395 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5904
Practice Address - Country:US
Practice Address - Phone:559-585-3937
Practice Address - Fax:559-582-3645
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9063T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0090630Medicare ID - Type Unspecified
U79543Medicare UPIN