Provider Demographics
NPI:1225115843
Name:STOCKSTAD, PHILIP BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BRADLEY
Last Name:STOCKSTAD
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 1:401 E 10TH AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3317
Mailing Address - Country:US
Mailing Address - Phone:541-683-2224
Mailing Address - Fax:541-683-2321
Practice Address - Street 1:401 E 10TH AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3317
Practice Address - Country:US
Practice Address - Phone:541-683-2224
Practice Address - Fax:541-683-2321
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1408 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR262162Medicaid
U30642Medicare UPIN
OR262162Medicaid