Provider Demographics
NPI:1518015759
Name:WILLIAMS, MARK P (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
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 1:4067 E COURT ST # 10-11
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2509
Mailing Address - Country:US
Mailing Address - Phone:810-715-2020
Mailing Address - Fax:
Practice Address - Street 1:4067 E COURT ST
Practice Address - Street 2:#10-11
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2509
Practice Address - Country:US
Practice Address - Phone:810-715-2020
Practice Address - Fax:810-715-2021
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002607152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI202115OtherMCLAREN PROVIDER NUMBER
MI900B56586OtherBCBS PROVIDER NUMBER
MI945104868Medicaid
MI382219845OtherALL OTHER INS
MIT32807Medicare UPIN
MI900B56586OtherBCBS PROVIDER NUMBER