Basic Information
| Provider Information | |||||||||
| NPI: | 1558402578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2178 PAINTER PL | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378659635 | ||||||||
| FaxNumber: | 9374271527 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 FAIRFIELD COMMONS BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454313778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374272779 | ||||||||
| FaxNumber: | 9374271527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5284 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 220039 | 01 | OH | EYEMED PROVIDER ID # | OTHER |