Provider Demographics
NPI:1497700074
Name:WILLIAMS, SALISA K (OD)
Entity Type:Individual
Prefix:
First Name:SALISA
Middle Name:K
Last Name:WILLIAMS
Suffix:
Gender:F
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2205 NE 129TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3252
Practice Address - Country:US
Practice Address - Phone:360-694-2544
Practice Address - Fax:360-694-1356
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3116ATI152W00000X
WAOD00004059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8883203OtherMEDICARE WA
G8893963OtherMEDICARE WA
WAP00378195OtherRAIL ROAD MEDICARE
WAG8882481OtherMEDICARE WA
WAG8925843OtherMEDICARE WA
WA2032092Medicaid
ORR134729Medicare PIN
WAG8860668Medicare PIN
WAG8860666Medicare PIN