Provider Demographics
NPI:1336214527
Name:WILLIAM R CHISM OD PC
Entity Type:Organization
Organization Name:WILLIAM R CHISM OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-581-5581
Mailing Address - Street 1:1000 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9163
Mailing Address - Country:US
Mailing Address - Phone:417-581-5581
Mailing Address - Fax:417-581-5511
Practice Address - Street 1:1000 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9163
Practice Address - Country:US
Practice Address - Phone:417-581-5581
Practice Address - Fax:417-581-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42553Medicare UPIN
MO990001776Medicare ID - Type Unspecified
MO4917230002Medicare NSC
MO990001575Medicare PIN