Provider Demographics
NPI:1649381955
Name:WILLIAMS, KYLE J (OD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:J
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:PO BOX 6129
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6129
Mailing Address - Country:US
Mailing Address - Phone:208-726-3363
Mailing Address - Fax:508-726-0138
Practice Address - Street 1:180 1ST AVE N
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-6129
Practice Address - Country:US
Practice Address - Phone:208-726-3363
Practice Address - Fax:208-726-0138
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807261300Medicaid
1594468Medicare ID - Type Unspecified
ID807261300Medicaid