Provider Demographics
NPI:1346266095
Name:WILLIAMS, GRADY JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:JOSEPH
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 1:5724 DESERT SKY WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-5130
Mailing Address - Country:US
Mailing Address - Phone:702-655-7476
Mailing Address - Fax:
Practice Address - Street 1:2400 W CHARLESTON BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2152
Practice Address - Country:US
Practice Address - Phone:702-870-5911
Practice Address - Fax:702-870-2368
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV296152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVT19586Medicare UPIN
NVV104278Medicare PIN