Provider Demographics
NPI:1720019029
Name:STALDER, KYLE JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JOHN
Last Name:STALDER
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 1:207 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-1906
Mailing Address - Country:US
Mailing Address - Phone:515-386-3513
Mailing Address - Fax:
Practice Address - Street 1:207 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-1906
Practice Address - Country:US
Practice Address - Phone:515-386-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1166322Medicaid
0547170006OtherDMERC
IA0166322Medicaid
IA2166322Medicaid
IA0547170001OtherDMERC
IA0547170004OtherDMERC
IA0547170005OtherDMERC
IA0724732Medicaid
IA4166322Medicaid
IA5166322Medicaid
IA0547170002OtherDMERC
IA1166322Medicaid
IA27170Medicare PIN
IA29248Medicare PIN
0547170006OtherDMERC
IA0166322Medicaid
IA2166322Medicaid