Provider Demographics
NPI:1831192533
Name:CUSUMANO, STEPHEN VINCENT (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:VINCENT
Last Name:CUSUMANO
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 1:2719 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-6925
Mailing Address - Country:US
Mailing Address - Phone:636-230-9097
Mailing Address - Fax:
Practice Address - Street 1:317 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2271
Practice Address - Country:US
Practice Address - Phone:636-391-3937
Practice Address - Fax:636-391-1345
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
91710001OtherPTAN
1831192533OtherNPI
MO431081796OtherFEDERAL TAX ID
MOU79727Medicare UPIN
MO000091171Medicare ID - Type Unspecified