Provider Demographics
NPI:1235120106
Name:COFFEE, WILLIAM C (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:COFFEE
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 597
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71802-0597
Mailing Address - Country:US
Mailing Address - Phone:870-777-3443
Mailing Address - Fax:870-777-3266
Practice Address - Street 1:405 W 16TH ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-7104
Practice Address - Country:US
Practice Address - Phone:870-777-3443
Practice Address - Fax:870-777-3266
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48688Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ART20222Medicare UPIN