Healthcare Provider Details

I. General information

NPI: 1063555282
Provider Name (Legal Business Name): SHAWN M STALDER OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 MAIN ST
HAMILTON OH
45013
US

IV. Provider business mailing address

1020 MAIN ST
HAMILTON OH
45013
US

V. Phone/Fax

Practice location:
  • Phone: 513-896-7641
  • Fax: 513-896-7641
Mailing address:
  • Phone: 513-896-7641
  • Fax: 513-896-7641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number52425
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: