=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295990372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORIA J. WILLINGHAM, O.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2008
-----------------------------------------------------
Last Update Date | 07/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 E BROADWAY ST
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-1889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-3111
-----------------------------------------------------
Fax | 618-443-2900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 E. BROADWAY ST.
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-3111
-----------------------------------------------------
Fax | 618-443-2900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. VICTORIA JEAN WILLINGHAM
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 618-443-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-007728
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------