Provider Demographics
NPI:1922396076
Name:WOO, STEPHANIE (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:WOO
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 1:383 LAKE HAVASU AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-9368
Mailing Address - Country:US
Mailing Address - Phone:928-680-1144
Mailing Address - Fax:928-680-8639
Practice Address - Street 1:383 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-9368
Practice Address - Country:US
Practice Address - Phone:928-680-1144
Practice Address - Fax:928-680-8639
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1812152W00000X
MO2011019156152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922396076Medicaid
MO1922396076Medicaid
MO067820020Medicare PIN
MO074730021Medicare PIN
AZZ155372Medicare PIN