Provider Demographics
NPI:1770501801
Name:STADELMAN, DAN L (OD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:L
Last Name:STADELMAN
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 1:1718 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2029
Mailing Address - Country:US
Mailing Address - Phone:563-355-3912
Mailing Address - Fax:563-359-4108
Practice Address - Street 1:1718 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2097
Practice Address - Country:US
Practice Address - Phone:563-355-3912
Practice Address - Fax:563-359-4108
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0224626Medicaid
IA22462OtherBC/BS OF IA
IAI14124Medicare ID - Type Unspecified
1770501801Medicare NSC
IA0224626Medicaid