Provider Demographics
NPI:1821343708
Name:WILLIAMS, JESSE CARL (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:CARL
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 1:1806 N. 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071
Mailing Address - Country:US
Mailing Address - Phone:270-759-1429
Mailing Address - Fax:270-759-1493
Practice Address - Street 1:1806 N. 4TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-759-1429
Practice Address - Fax:270-759-1493
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1909DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100327030Medicaid