Provider Demographics
NPI:1184698615
Name:WILLIAMS, PENNY S (OD)
Entity type:Individual
Prefix:DR
First Name:PENNY
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 1:3725 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3410
Mailing Address - Country:US
Mailing Address - Phone:515-279-2020
Mailing Address - Fax:515-255-8002
Practice Address - Street 1:3735 NW 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4008
Practice Address - Country:US
Practice Address - Phone:515-270-8545
Practice Address - Fax:515-270-0548
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1506956Medicaid
IA45719OtherBLUE CROSS
U50648Medicare UPIN
IA1506956Medicaid