Provider Demographics
NPI:1295990372
Name:VICTORIA J. WILLINGHAM, O.D., P.C.
Entity type:Organization
Organization Name:VICTORIA J. WILLINGHAM, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-443-3111
Mailing Address - Street 1:520 E. BROADWAY ST.
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1816
Mailing Address - Country:US
Mailing Address - Phone:618-443-3111
Mailing Address - Fax:618-443-2900
Practice Address - Street 1:520 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1889
Practice Address - Country:US
Practice Address - Phone:618-443-3111
Practice Address - Fax:618-443-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38326Medicare UPIN