Basic Information
| Provider Information | |||||||||
| NPI: | 1427043652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | ELWOOD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OPTICIAN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | WOODY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OPTICIAN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 TOWNE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FRANKLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450055543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134245217 | ||||||||
| FaxNumber: | 5134240205 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWNE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FRANKLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450055543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134245217 | ||||||||
| FaxNumber: | 5134240205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 2467SC | OH | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 0259107 | 05 | OH | MEDICAID |