Provider Demographics
NPI:1972162345
Name:HAIDET, STEPHEN JOHN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:HAIDET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9617 GULF RESEARCH LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4555
Mailing Address - Country:US
Mailing Address - Phone:239-418-0262
Mailing Address - Fax:239-274-0773
Practice Address - Street 1:9617 GULF RESEARCH LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4555
Practice Address - Country:US
Practice Address - Phone:239-418-0262
Practice Address - Fax:239-274-0773
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5695152W00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program