Provider Demographics
NPI:1750766325
Name:WILLIAMS, WYATT (OD)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
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 1:17900 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5494
Mailing Address - Country:US
Mailing Address - Phone:918-207-0700
Mailing Address - Fax:918-207-0211
Practice Address - Street 1:17900 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5494
Practice Address - Country:US
Practice Address - Phone:918-207-0700
Practice Address - Fax:918-207-0211
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist