Provider Demographics
NPI:1659320117
Name:STAHL, J DOUGLAS (OD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:DOUGLAS
Last Name:STAHL
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 1:320 A AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3056
Mailing Address - Country:US
Mailing Address - Phone:503-636-2762
Mailing Address - Fax:503-636-4502
Practice Address - Street 1:320 A AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3056
Practice Address - Country:US
Practice Address - Phone:503-636-2762
Practice Address - Fax:503-636-4502
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1088T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164525Medicaid
OR164525Medicaid
OOOOPHFTXMedicare UPIN