Provider Demographics
NPI:1881651511
Name:STOTT, AMANDA J (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:J
Last Name:STOTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:SCHOFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:16800 WEST CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:
Practice Address - Street 1:280 N PHELPS AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2498
Practice Address - Country:US
Practice Address - Phone:815-986-1900
Practice Address - Fax:815-986-1902
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009775152W00000X
WI3024035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9775OtherEYEMED VISION NO.
V06134Medicare UPIN