Provider Demographics
NPI:1750472593
Name:STOLL, CONRAD WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:WILLIAM
Last Name:STOLL
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 1:214 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5111
Mailing Address - Country:US
Mailing Address - Phone:630-668-4144
Mailing Address - Fax:630-668-7559
Practice Address - Street 1:214 W FRONT ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5111
Practice Address - Country:US
Practice Address - Phone:630-668-4144
Practice Address - Fax:630-668-7559
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36278Medicare UPIN
316780Medicare ID - Type Unspecified
IL0234430001Medicare NSC