Provider Demographics
NPI:1508947276
Name:WILLIAMS, MARK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:307 SAGAMORE PKWY W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1500
Mailing Address - Country:US
Mailing Address - Phone:765-463-4558
Mailing Address - Fax:765-497-2154
Practice Address - Street 1:307 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1500
Practice Address - Country:US
Practice Address - Phone:765-463-4558
Practice Address - Fax:765-497-2154
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003424A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003424AOtherINDIANA LICENSE
IN5419240013Medicare NSC
INM400066651Medicare PIN
INM400066651Medicare PIN
IN5419240013Medicare NSC