Provider Demographics
NPI:1053387530
Name:STROUD, CHRISTOPHER LOGAN
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:LOGAN
Last Name:STROUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W 14TH ST STE 100A
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3751
Mailing Address - Country:US
Mailing Address - Phone:812-280-2162
Mailing Address - Fax:812-284-3822
Practice Address - Street 1:1220 W MCCLAIN AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1167
Practice Address - Country:US
Practice Address - Phone:812-590-6157
Practice Address - Fax:812-284-3822
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1617DT152W00000X
IN18003276A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00301581OtherMEDICARE RR
0351OtherMEDICARE GROUP PIN
000000389918OtherBLUE SHIED
KY77001519Medicaid
CB0333OtherGROUP RAILROAD MEDICARE
000000389918OtherBLUE SHIED
0268650001Medicare NSC
0351OtherMEDICARE GROUP PIN