Basic Information
| Provider Information | |||||||||
| NPI: | 1114935095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIERRE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD TPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545200396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 MISHKOSEN DR | ||||||||
| Address2: | FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER | ||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1897035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38523300 | 05 | WI | MEDICAID | 72023 | 01 | WI | SECURITY HEALTH PLAN | OTHER |