Basic Information
Provider Information | |||||||||
NPI: | 1205367182 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4445 LAKE FOREST DR STE 600 | ||||||||
Address2: |   | ||||||||
City: | BLUE ASH | ||||||||
State: | OH | ||||||||
PostalCode: | 452423744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135693741 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1945 CEI DR | ||||||||
Address2: |   | ||||||||
City: | BLUE ASH | ||||||||
State: | OH | ||||||||
PostalCode: | 452425664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5139845133 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2017 | ||||||||
LastUpdateDate: | 06/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 55075 | KY | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207W00000X | 35141487 | OH | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 0439822 | 05 | OH |   | MEDICAID |