Provider Demographics
NPI:1528003589
Name:WILLIAMS, BRET D (OD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:D
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 1:3045 E ST LUKES ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3507
Mailing Address - Country:US
Mailing Address - Phone:208-706-2020
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD STE 2203
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6354
Practice Address - Country:US
Practice Address - Phone:208-706-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V07734Medicare UPIN
ID5854480001Medicare NSC
ID1594506Medicare PIN