Provider Demographics
NPI:1962926253
Name:SOUVANNACHAK-COWICK, STEPHANIE P (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:P
Last Name:SOUVANNACHAK-COWICK
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 1:113 E 125TH CT S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-1075
Mailing Address - Country:US
Mailing Address - Phone:479-871-7525
Mailing Address - Fax:
Practice Address - Street 1:10920 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7352
Practice Address - Country:US
Practice Address - Phone:918-366-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist