Healthcare Provider Details

I. General information

NPI: 1245239581
Provider Name (Legal Business Name): BRYAN ANDREW STAM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10915 BAYMEADOWS RD STE 110
JACKSONVILLE FL
32256-9131
US

IV. Provider business mailing address

10915 BAYMEADOWS RD STE 110
JACKSONVILLE FL
32256-9131
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-9655
  • Fax: 904-647-9611
Mailing address:
  • Phone: 904-647-9655
  • Fax: 904-647-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 3453
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC 3453
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: