Provider Demographics
NPI:1275054918
Name:WUSTMAN, STACEY KAY (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:KAY
Last Name:WUSTMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 RIVER RUN ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8818
Mailing Address - Country:US
Mailing Address - Phone:616-403-2192
Mailing Address - Fax:
Practice Address - Street 1:3232 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1439
Practice Address - Country:US
Practice Address - Phone:616-669-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist