Provider Demographics
NPI:1245239581
Name:STAM, BRYAN ANDREW (OD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANDREW
Last Name:STAM
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 1:104 NINA CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2429
Mailing Address - Country:US
Mailing Address - Phone:904-273-3149
Mailing Address - Fax:
Practice Address - Street 1:905 BEACH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4303
Practice Address - Country:US
Practice Address - Phone:904-246-4831
Practice Address - Fax:904-249-5876
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3453152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620556900Medicaid
FL620603400Medicaid
FLU82990 0001Medicare UPIN
FL2049ZMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
FL620603400Medicaid