Provider Demographics
NPI:1720186117
Name:WILLIAMS, SAMUEL (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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 1:112 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6350
Mailing Address - Country:US
Mailing Address - Phone:352-787-1956
Mailing Address - Fax:352-365-6690
Practice Address - Street 1:112 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6350
Practice Address - Country:US
Practice Address - Phone:352-787-1956
Practice Address - Fax:352-365-6690
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC968152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078718300Medicaid
FL0671730001Medicare NSC
FL19921Medicare ID - Type Unspecified
FLT85171Medicare UPIN