Provider Demographics
NPI:1942619275
Name:WILLIAMS, BLAKE THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:THOMAS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2394 H G MOSLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-3661
Mailing Address - Country:US
Mailing Address - Phone:903-234-0771
Mailing Address - Fax:903-234-0775
Practice Address - Street 1:2394 H G MOSLEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-3661
Practice Address - Country:US
Practice Address - Phone:903-234-0771
Practice Address - Fax:903-234-0775
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8513T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist