Provider Demographics
NPI:1063555282
Name:STALDER, SHAWN M (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:M
Last Name:STALDER
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013
Mailing Address - Country:US
Mailing Address - Phone:513-896-7641
Mailing Address - Fax:513-896-7641
Practice Address - Street 1:1020 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-896-7641
Practice Address - Fax:513-896-7641
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH52425152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2027265Medicaid
OH925027OtherAMERIGROUP