Healthcare Provider Details

I. General information

NPI: 1720838873
Provider Name (Legal Business Name): WALTER KEANDRE DESEAN WILLIAMS IV OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WALT WILLIAMS IV

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 STATE ST
NEW ALBANY IN
47150-3620
US

IV. Provider business mailing address

519 STATE ST
NEW ALBANY IN
47150-3620
US

V. Phone/Fax

Practice location:
  • Phone: 812-948-0616
  • Fax:
Mailing address:
  • Phone: 812-948-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004506A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: