Provider Demographics
NPI:1003298928
Name:HILL, ELENA LOPEZ (OD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:LOPEZ
Last Name:HILL
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 1:1500 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2522
Mailing Address - Country:US
Mailing Address - Phone:573-888-5331
Mailing Address - Fax:
Practice Address - Street 1:1500 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2522
Practice Address - Country:US
Practice Address - Phone:573-888-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2721152W00000X
MO2017028246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210168722Medicaid