Provider Demographics
NPI:1083787030
Name:WILLER, PATRICK ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:ALLEN
Last Name:WILLER
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 1:3911 E STATE ROUTE 69
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6717
Mailing Address - Country:US
Mailing Address - Phone:928-442-0707
Mailing Address - Fax:
Practice Address - Street 1:3911 E STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6717
Practice Address - Country:US
Practice Address - Phone:928-442-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02051Medicare UPIN