Provider Demographics
NPI:1528581527
Name:STALLBAUMER, JACOB LEO (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LEO
Last Name:STALLBAUMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:1130 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2023
Practice Address - Country:US
Practice Address - Phone:312-226-7200
Practice Address - Fax:312-226-6490
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011248152W00000X
TN3401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist