Provider Demographics
NPI:1639240955
Name:CHISM, WILLIAM R (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:CHISM
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 1:1000 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9163
Mailing Address - Country:US
Mailing Address - Phone:417-581-5581
Mailing Address - Fax:417-581-5511
Practice Address - Street 1:1000 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9163
Practice Address - Country:US
Practice Address - Phone:417-581-5581
Practice Address - Fax:417-581-5511
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4917230002OtherDMERC REGION D
MO310415237Medicaid
MO310415245Medicaid
MO310415245Medicaid
MO990001776Medicare ID - Type Unspecified