Provider Demographics
NPI:1144201385
Name:WILLARD C PEARCE JR OD PA
Entity Type:Organization
Organization Name:WILLARD C PEARCE JR OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:CAIL
Authorized Official - Last Name:PEARCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:863-676-2020
Mailing Address - Street 1:254 E STUART AVE
Mailing Address - Street 2:PO BOX 3806
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-5720
Mailing Address - Country:US
Mailing Address - Phone:863-676-2020
Mailing Address - Fax:863-676-4500
Practice Address - Street 1:254 E STUART AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-5720
Practice Address - Country:US
Practice Address - Phone:863-676-2020
Practice Address - Fax:863-676-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1299152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U22772Medicare UPIN
FL19208Medicare ID - Type Unspecified