Provider Demographics
NPI:1932157427
Name:SPOONER, WILLIAM RONALD (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RONALD
Last Name:SPOONER
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 1:321 N BROAD ST
Mailing Address - Street 2:P. O. BOX 487
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2110
Mailing Address - Country:US
Mailing Address - Phone:229-377-5432
Mailing Address - Fax:229-377-5012
Practice Address - Street 1:321 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2110
Practice Address - Country:US
Practice Address - Phone:229-377-5432
Practice Address - Fax:229-377-5012
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000110492AMedicaid
GA000110492AMedicaid
GA41ZCFLVMedicare ID - Type UnspecifiedMEDICARE #