Provider Demographics
NPI:1407118169
Name:WILLIAMSON, RILEY (OD)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:WILLIAMSON
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 1:560 E CONTINENTAL ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614
Mailing Address - Country:US
Mailing Address - Phone:520-625-5673
Mailing Address - Fax:520-625-6259
Practice Address - Street 1:560 E CONTINENTAL ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614
Practice Address - Country:US
Practice Address - Phone:520-625-5673
Practice Address - Fax:520-625-6259
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1887152W00000X
OR3451ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162075Medicare PIN
AZZ162939Medicare PIN
AZZ162076Medicare PIN