Provider Demographics
NPI:1558496182
Name:ROBERT J STAHL & AMY J CALDER, ODS - A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT J STAHL & AMY J CALDER, ODS - A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:STAHL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-323-5095
Mailing Address - Street 1:1142 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3538
Mailing Address - Country:US
Mailing Address - Phone:310-323-5095
Mailing Address - Fax:310-323-6046
Practice Address - Street 1:1142 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3538
Practice Address - Country:US
Practice Address - Phone:310-323-5095
Practice Address - Fax:310-323-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9599T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005020Medicaid
CAGSD005020Medicaid
CA0609260001Medicare NSC