Provider Demographics
NPI:1083886329
Name:WILLARD J. STAMP
Entity Type:Organization
Organization Name:WILLARD J. STAMP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:STAMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-332-1200
Mailing Address - Street 1:389 N ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-2805
Mailing Address - Country:US
Mailing Address - Phone:330-332-1200
Mailing Address - Fax:
Practice Address - Street 1:389 N ELLSWORTH AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2805
Practice Address - Country:US
Practice Address - Phone:330-332-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2549-T972332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8368332Medicaid
OH3995830001Medicare NSC
OH1518050806Medicare UPIN
OHST0156941Medicare PIN