Provider Demographics
NPI:1053342410
Name:BECK, STACEY (OD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BECK
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 1:1601 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2268
Mailing Address - Country:US
Mailing Address - Phone:765-464-8573
Mailing Address - Fax:
Practice Address - Street 1:1850 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1368
Practice Address - Country:US
Practice Address - Phone:765-743-3132
Practice Address - Fax:765-743-2455
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003044B152WC0802X
IN18003044A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200269560Medicaid
IN177010AMedicare ID - Type Unspecified
IN200269560Medicaid