1225115843 NPI number — DR. PHILIP BRADLEY STOCKSTAD O.D.

Table of content: DR. PHILIP BRADLEY STOCKSTAD O.D. (NPI 1225115843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225115843 NPI number — DR. PHILIP BRADLEY STOCKSTAD O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOCKSTAD
Provider First Name:
PHILIP
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225115843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 E 10TH AVE
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-3317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-683-2224
Provider Business Mailing Address Fax Number:
541-683-2321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 E 10TH AVE
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-683-2224
Provider Business Practice Location Address Fax Number:
541-683-2321
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1408 ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 262162 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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