Provider Demographics
NPI:1942309893
Name:STAHL, JERRY L (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:STAHL
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 1:999 HOME PLZ
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4822
Mailing Address - Country:US
Mailing Address - Phone:319-236-0815
Mailing Address - Fax:319-234-0847
Practice Address - Street 1:999 HOME PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4822
Practice Address - Country:US
Practice Address - Phone:319-236-0815
Practice Address - Fax:319-234-0847
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0117267Medicaid
IA18418OtherBLUE CROSS BLUE SHIELD
IA410026798OtherMEDICARE ID
IACG4244OtherMEDICARE ID
IA0117267Medicaid
IA0358460003Medicare NSC
IA0358460001Medicare NSC
IA18418OtherBLUE CROSS BLUE SHIELD