Provider Demographics
NPI:1750424461
Name:STACY, WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 COLD SPRINGS RD STE B
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4236
Mailing Address - Country:US
Mailing Address - Phone:530-626-7460
Mailing Address - Fax:
Practice Address - Street 1:2920 COLD SPRINGS RD STE B
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-626-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5233T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052331Medicaid
CASD0052331Medicaid