Provider Demographics
NPI:1679592133
Name:STADER, JOHN DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:STADER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 ELDORADO DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2601
Mailing Address - Country:US
Mailing Address - Phone:563-355-2020
Mailing Address - Fax:
Practice Address - Street 1:2400 18TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3280
Practice Address - Country:US
Practice Address - Phone:563-355-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06575111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA34148OtherBLUE CROSS BLUE SHIELD
IA34148OtherBLUE CROSS BLUE SHIELD