Provider Demographics
NPI:1053462739
Name:STAUDER, MICHAEL F (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:STAUDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 N MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3291
Mailing Address - Country:US
Mailing Address - Phone:217-872-7200
Mailing Address - Fax:217-872-0920
Practice Address - Street 1:2980 N MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-872-7200
Practice Address - Fax:217-872-0920
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007131Medicaid
IL1864FOtherCATERPILLAR
05821564OtherBLUE CROSS BLUE SHIELD
IL1864FOtherUNITED HEALTH CARE, CAT
IL1864FOtherUNITED HEALTH CARE, CAT
IL2551890001Medicare NSC
IL1864FOtherCATERPILLAR