Provider Demographics
NPI:1336297662
Name:WILLIAMS, TIMOTHY LEE (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEE
Last Name:WILLIAMS
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 1:505 E GRANT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-836-3937
Mailing Address - Fax:309-833-1894
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:SUITE 206
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-836-3937
Practice Address - Fax:309-833-1894
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480120Medicare ID - Type UnspecifiedMCDONOUGH EYE ASSOC., GRP
U58416Medicare UPIN
IL1232350001Medicare NSC