Provider Demographics
NPI:1023009610
Name:STANLEY, SCOTT LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LAWRENCE
Last Name:STANLEY
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 1:371 NE GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2039
Mailing Address - Country:US
Mailing Address - Phone:541-673-4166
Mailing Address - Fax:
Practice Address - Street 1:371 NE GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2039
Practice Address - Country:US
Practice Address - Phone:541-673-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2885AT152W00000X
WAOD3772152W00000X
CAOPT11957TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182779OtherOREGON HEALTH PLAN NUMBER
804858000OtherBLUE CROSS PROVIDER NUMBE
U90505Medicare UPIN
0345750001Medicare NSC
ORR113353Medicare PIN