Provider Demographics
NPI:1326068685
Name:WADDLE, STACIA R (OD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:R
Last Name:WADDLE
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 1:50 N PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1757
Mailing Address - Country:US
Mailing Address - Phone:740-774-4434
Mailing Address - Fax:740-774-4061
Practice Address - Street 1:50 N PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1757
Practice Address - Country:US
Practice Address - Phone:740-774-4434
Practice Address - Fax:740-774-4061
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5666/T2580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4185482Medicare PIN
OH4185483Medicare PIN
OH4185488Medicare PIN
OH4185486Medicare PIN
OHH055441Medicare PIN
OHH055440Medicare PIN
OHH055489Medicare PIN
OH4185481Medicare PIN