Provider Demographics
NPI:1205943487
Name:WILLIAMS, LARRY EARL (OD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:EARL
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 1:10 AMALIA DR
Mailing Address - Street 2:SUITE C1
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2271
Mailing Address - Country:US
Mailing Address - Phone:304-472-9160
Mailing Address - Fax:
Practice Address - Street 1:10 AMALIA DR
Practice Address - Street 2:SUITE C1
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2271
Practice Address - Country:US
Practice Address - Phone:304-472-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV683 ODWV152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV410019766OtherRAILROAD MEDICARE
WV001719808OtherBLUE CROSS BLUE SHIELD
WV1034014OtherUMWA
WV0168470001Medicare NSC
WV001719808OtherBLUE CROSS BLUE SHIELD
WV1034014OtherUMWA