Provider Demographics
NPI:1699774901
Name:CAJACOB, STEPHEN N (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:N
Last Name:CAJACOB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2730
Mailing Address - Country:US
Mailing Address - Phone:419-228-8116
Mailing Address - Fax:419-228-1160
Practice Address - Street 1:1034 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2730
Practice Address - Country:US
Practice Address - Phone:419-228-8116
Practice Address - Fax:419-228-1160
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2935T377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000129223OtherANTHEM PROVIDER NUMBER
OH0159570001OtherMEDICARE DMERC
OH0231270Medicaid
OH000000129223OtherANTHEM PROVIDER NUMBER
OHT46910Medicare UPIN