Provider Demographics
NPI:1326080169
Name:STOLLER, KENNETH STUART (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STUART
Last Name:STOLLER
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 1:39259 HEATHERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2916
Mailing Address - Country:US
Mailing Address - Phone:313-382-9650
Mailing Address - Fax:313-382-3428
Practice Address - Street 1:1755 DIX HWY
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1412
Practice Address - Country:US
Practice Address - Phone:313-382-9650
Practice Address - Fax:313-382-3428
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002772152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU26114Medicare UPIN
MIH27940002Medicare ID - Type Unspecified