Provider Demographics
NPI:1508043019
Name:DAVID THOMAS WILLIAMS
Entity Type:Organization
Organization Name:DAVID THOMAS WILLIAMS
Other - Org Name:BRIDGEPORT VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-588-2254
Mailing Address - Street 1:9101 BRIDGEPORT WAY SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499
Mailing Address - Country:US
Mailing Address - Phone:253-588-2254
Mailing Address - Fax:253-588-0545
Practice Address - Street 1:9101 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-588-2254
Practice Address - Fax:253-588-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1624TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130052Medicaid
T01983Medicare UPIN
0313670001Medicare NSC
G001001757Medicare PIN