Provider Demographics
NPI:1558052365
Name:STOLER, JACOB SAMUEL (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SAMUEL
Last Name:STOLER
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 1:2435 COMMERCE AVE BLDG 2200
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4980
Mailing Address - Country:US
Mailing Address - Phone:770-872-3600
Mailing Address - Fax:
Practice Address - Street 1:3752 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1142
Practice Address - Country:US
Practice Address - Phone:614-591-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist