Provider Demographics
NPI:1730346172
Name:CLARK, STEPHANIE LEE (OD)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:LEE
Other - Last Name:CLARK-RAYESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3205 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2740
Mailing Address - Country:US
Mailing Address - Phone:510-444-0666
Mailing Address - Fax:510-463-2888
Practice Address - Street 1:3205 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2740
Practice Address - Country:US
Practice Address - Phone:510-444-0666
Practice Address - Fax:510-463-2888
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11869T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist