Provider Demographics
NPI:1710007711
Name:WILLIAMS, KENNETH WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WALTER
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 1:6584 E STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3825
Mailing Address - Country:US
Mailing Address - Phone:928-442-9202
Mailing Address - Fax:928-442-3980
Practice Address - Street 1:3250 GATEWAY BLVD
Practice Address - Street 2:#152
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6849
Practice Address - Country:US
Practice Address - Phone:928-442-9202
Practice Address - Fax:928-442-3980
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
76800Medicare ID - Type Unspecified
AZU83602Medicare UPIN