Healthcare Provider Details

I. General information

NPI: 1912499765
Provider Name (Legal Business Name): ZACHARY STAPLETON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 STATE ROUTE 28
MILFORD OH
45150-4940
US

IV. Provider business mailing address

PO BOX 207170
DALLAS TX
75320-7156
US

V. Phone/Fax

Practice location:
  • Phone: 513-831-3166
  • Fax: 513-831-2933
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6664
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: