Provider Demographics
NPI:1245402619
Name:JERRY W WILLIAMS OD
Entity Type:Organization
Organization Name:JERRY W WILLIAMS OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-628-6233
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:318-628-6233
Mailing Address - Fax:
Practice Address - Street 1:1605 WEST COURT ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483
Practice Address - Country:US
Practice Address - Phone:318-628-6233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1041041Medicaid
0201860001Medicare NSC
T19647Medicare UPIN