Provider Demographics
NPI:1306983648
Name:STACK, ANDREW DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:DAVID
Last Name:STACK
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1457 WHALLEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1153
Practice Address - Country:US
Practice Address - Phone:203-387-3937
Practice Address - Fax:203-389-3994
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U-27431Medicare UPIN
410000546Medicare ID - Type Unspecified