Provider Demographics
NPI:1053308114
Name:WILLIAMS, JERRY W (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:WILLIAMS
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:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 W COURT ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-2653
Practice Address - Country:US
Practice Address - Phone:318-628-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA618203T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0201860001OtherPALMETTA GBA
LA1041041Medicaid
LA1041041Medicaid
0201860001OtherPALMETTA GBA
0201860001Medicare NSC