Provider Demographics
NPI:1457765604
Name:HILL, STACY JO (OD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:JO
Last Name:HILL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:JO
Other - Last Name:KOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4655 SW GRIFFITH DR STE 165
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-8731
Mailing Address - Country:US
Mailing Address - Phone:503-646-8592
Mailing Address - Fax:
Practice Address - Street 1:4655 SW GRIFFITH DR STE 165
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-8731
Practice Address - Country:US
Practice Address - Phone:503-646-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3548ATI152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673809Medicaid