Healthcare Provider Details

I. General information

NPI: 1639142946
Provider Name (Legal Business Name): GARY J WILLIAMS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 MAIN ST
OWEGO NY
13827-1615
US

IV. Provider business mailing address

293 MAIN ST
OWEGO NY
13827-1615
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-3391
  • Fax: 607-687-4226
Mailing address:
  • Phone: 607-687-3391
  • Fax: 607-687-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: