Healthcare Provider Details

I. General information

NPI: 1316946338
Provider Name (Legal Business Name): BRYAN MATTHEW STOLLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N LADD ST
PONTIAC IL
61764-1612
US

IV. Provider business mailing address

320 N LADD ST
PONTIAC IL
61764-1612
US

V. Phone/Fax

Practice location:
  • Phone: 815-842-4304
  • Fax: 815-844-5495
Mailing address:
  • Phone: 815-842-4304
  • Fax: 815-844-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: