Provider Demographics
NPI:1447347224
Name:STILLEY, JUSTIN L (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:L
Last Name:STILLEY
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 1:1602 S. RANGELINE RD.
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-553-9903
Mailing Address - Fax:417-385-1955
Practice Address - Street 1:1602 S. RANGELINE RD.
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-553-9903
Practice Address - Fax:417-385-1955
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017015152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS318383007Medicaid
MO000091371Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MOU90660Medicare UPIN