Provider Demographics
NPI:1528032430
Name:WILLIAMS, ROBERT TRACY (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TRACY
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(LUH-NORTH ENT., RM. 2601)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3408
Mailing Address - Fax:708-216-3557
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(LUH-NORTH ENT., RM. 2601)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3408
Practice Address - Fax:708-216-3557
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46007266207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL46007266Medicaid
IL46007266Medicaid
IL503590Medicare ID - Type Unspecified