1720179997 NPI number — CHANDRA M WILLIAMS O.D.

Table of content: CHANDRA M WILLIAMS O.D. (NPI 1720179997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720179997 NPI number — CHANDRA M WILLIAMS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
CHANDRA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720179997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13453 N MAIN ST STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32218-2773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-696-2027
Provider Business Mailing Address Fax Number:
904-696-2028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13453 N MAIN ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32218-2773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-696-2027
Provider Business Practice Location Address Fax Number:
904-696-2028
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001840 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00462502 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 36102 . This is a "BCBS INDIVIDUAL ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002378300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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