Provider Demographics
NPI:1861446510
Name:WILLIAMS, TERRY LANCE (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LANCE
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 1:1496 N HIGLEY RD
Mailing Address - Street 2:104
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1496 N HIGLEY RD
Practice Address - Street 2:104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1601
Practice Address - Country:US
Practice Address - Phone:480-279-4400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ73970801Medicaid
AZ71091Medicare ID - Type UnspecifiedPROVIDER #
AZ73970801Medicaid