Provider Demographics
NPI:1558402578
Name:ANDERSON, STACI DAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:STACI
Middle Name:DAWN
Last Name:ANDERSON
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 1:2178 PAINTER PL
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3982
Mailing Address - Country:US
Mailing Address - Phone:937-865-9635
Mailing Address - Fax:937-427-1527
Practice Address - Street 1:2727 FAIRFIELD COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3778
Practice Address - Country:US
Practice Address - Phone:937-427-2779
Practice Address - Fax:937-427-1527
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5284152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH220039OtherEYEMED PROVIDER ID #