Provider Demographics
NPI:1053376434
Name:CALLOWAY, STEFAN A (OD)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:A
Last Name:CALLOWAY
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 1:713 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-4805
Mailing Address - Country:US
Mailing Address - Phone:870-673-8529
Mailing Address - Fax:870-673-2931
Practice Address - Street 1:713 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-4805
Practice Address - Country:US
Practice Address - Phone:870-673-8529
Practice Address - Fax:870-673-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2290152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0542740001Medicare NSC
AR49466Medicare PIN
ART20315Medicare UPIN