Provider Demographics
NPI:1750479457
Name:STAUDER, PAUL B
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:STAUDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-0506
Mailing Address - Country:US
Mailing Address - Phone:618-842-6516
Mailing Address - Fax:
Practice Address - Street 1:101 E DELAWARE ST
Practice Address - Street 2:SUITE C
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2111
Practice Address - Country:US
Practice Address - Phone:618-842-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009085Medicaid
ILU72547Medicare UPIN
IL046009085Medicaid
IL509080Medicare ID - Type Unspecified