Provider Demographics
NPI:1154761641
Name:STEFANOVIC, ELISA (OD)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:STEFANOVIC
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 1:8787 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2806
Mailing Address - Country:US
Mailing Address - Phone:718-465-4999
Mailing Address - Fax:
Practice Address - Street 1:8787 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2806
Practice Address - Country:US
Practice Address - Phone:718-465-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist