Healthcare Provider Details

I. General information

NPI: 1801810189
Provider Name (Legal Business Name): SCOTT DALE STAATZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 MILLER ST
BETHANY MO
64424-2704
US

IV. Provider business mailing address

2707 MILLER ST
BETHANY MO
64424-2704
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-8116
  • Fax: 660-425-3418
Mailing address:
  • Phone: 660-425-8116
  • Fax: 660-425-3418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO3394
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: