Provider Demographics
NPI:1518050806
Name:STAMP, WILLARD J (OD)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:J
Last Name:STAMP
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 1:389 N ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-2805
Mailing Address - Country:US
Mailing Address - Phone:330-332-1200
Mailing Address - Fax:330-332-1200
Practice Address - Street 1:389 N ELLSWORTH AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2805
Practice Address - Country:US
Practice Address - Phone:330-332-1200
Practice Address - Fax:330-332-1200
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2008-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2549/T972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3409444920OtherBUREAU OF WORKERS COMP
OH8368332Medicaid
OH8368332Medicaid