Provider Demographics
NPI:1821288820
Name:WILLIAMS, NICOLE S (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 E WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-3955
Mailing Address - Country:US
Mailing Address - Phone:610-543-8202
Mailing Address - Fax:610-543-8205
Practice Address - Street 1:910 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3955
Practice Address - Country:US
Practice Address - Phone:610-543-8202
Practice Address - Fax:610-543-8205
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA076899Medicare PIN
PAX04661Medicare UPIN