Provider Demographics
NPI:1235204587
Name:TERESA A E WILLS OD
Entity Type:Organization
Organization Name:TERESA A E WILLS OD
Other - Org Name:TERESA A ERICKSON OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-927-5252
Mailing Address - Street 1:900 MERIDIAN AVE E STE 18
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-7003
Mailing Address - Country:US
Mailing Address - Phone:253-927-5252
Mailing Address - Fax:253-927-4270
Practice Address - Street 1:900 MERIDIAN AVE E STE 18
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-7003
Practice Address - Country:US
Practice Address - Phone:253-927-5252
Practice Address - Fax:253-927-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022119Medicaid
WAGAB33541Medicare PIN