Provider Demographics
NPI:1013121680
Name:WILLIAMSTOWN EYE CLINIC INC.
Entity Type:Organization
Organization Name:WILLIAMSTOWN EYE CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMITRIST
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KOERBER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-375-6468
Mailing Address - Street 1:442 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-1249
Mailing Address - Country:US
Mailing Address - Phone:304-375-6468
Mailing Address - Fax:304-375-6468
Practice Address - Street 1:442 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187-1249
Practice Address - Country:US
Practice Address - Phone:304-375-6468
Practice Address - Fax:304-375-6468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV937-0D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149872000Medicaid
WV4036041Medicare PIN
WVU60328Medicare UPIN
WV0149872000Medicaid