Provider Demographics
NPI:1780668491
Name:WENGER BOWLING, STACEY R (OD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:WENGER BOWLING
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:R
Other - Last Name:WENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1000 JAMES EPPS ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2030
Mailing Address - Country:US
Mailing Address - Phone:417-334-7291
Mailing Address - Fax:417-334-6156
Practice Address - Street 1:1000 JAMES EPPS ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2030
Practice Address - Country:US
Practice Address - Phone:417-334-7291
Practice Address - Fax:417-334-6156
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318591302Medicaid
MO000006128OtherGROUP MEDICARE #
MO115578OtherBLUE CROSS BLUE SHIELD
MO0420260001Medicare NSC
MO0420260003Medicare NSC
MO006006128Medicare ID - Type Unspecified
MO000006128OtherGROUP MEDICARE #
U63346Medicare UPIN
MO318591302Medicaid