Provider Demographics
NPI:1871155168
Name:OH, STEPHANIE (OD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OH
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 BROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7109
Mailing Address - Country:US
Mailing Address - Phone:805-545-8100
Mailing Address - Fax:
Practice Address - Street 1:3855 BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7109
Practice Address - Country:US
Practice Address - Phone:805-545-8100
Practice Address - Fax:805-548-8785
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1085152W00000X
390200000X
CA35822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871155168Medicaid
NV1871155168Medicaid