Provider Demographics
NPI:1053393645
Name:TERRY L WILLIAMS O D INC
Entity type:Organization
Organization Name:TERRY L WILLIAMS O D INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-843-1445
Mailing Address - Street 1:12 WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1529
Mailing Address - Country:US
Mailing Address - Phone:304-843-1445
Mailing Address - Fax:304-843-1446
Practice Address - Street 1:12 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1529
Practice Address - Country:US
Practice Address - Phone:304-843-1445
Practice Address - Fax:304-843-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV645D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720254OtherMOUNTAIN STATE BLUE CROSS
WV0804171Medicare PIN
WV0141480001Medicare NSC