Provider Demographics
NPI:1861449225
Name:ECENBARGER, STACI DAWN (OD)
Entity type:Individual
Prefix:DR
First Name:STACI
Middle Name:DAWN
Last Name:ECENBARGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 BYRON CENTER AVE SW
Mailing Address - Street 2:SUITE V
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9621
Mailing Address - Country:US
Mailing Address - Phone:616-532-2020
Mailing Address - Fax:616-532-2022
Practice Address - Street 1:5751 BYRON CENTER AVE SW
Practice Address - Street 2:SUITE V
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9621
Practice Address - Country:US
Practice Address - Phone:616-532-2020
Practice Address - Fax:616-532-2022
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5189909Medicaid
MIU82022Medicare UPIN
MI5189909Medicaid
MI0P32620Medicare PIN
MIP32620006Medicare PIN