Provider Demographics
NPI:1205979242
Name:HERREN, WILLIAM ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALLEN
Last Name:HERREN
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 1:831 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-7240
Mailing Address - Country:US
Mailing Address - Phone:912-884-5556
Mailing Address - Fax:
Practice Address - Street 1:15 MILL CREEK CIRCLE
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-748-9646
Practice Address - Fax:912-748-9664
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA881152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41CZZTZMedicare ID - Type Unspecified
GAI27041Medicare UPIN
GAU27041Medicare UPIN