Provider Demographics
NPI:1104174150
Name:WILLIAM R. WALDRON, O.D. LC
Entity type:Organization
Organization Name:WILLIAM R. WALDRON, O.D. LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-596-5666
Mailing Address - Street 1:1215 GEORGE WASHINGTON MEM HWY STE V
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-4316
Mailing Address - Country:US
Mailing Address - Phone:757-596-5666
Mailing Address - Fax:757-596-9755
Practice Address - Street 1:1215 GEORGE WASHINGTON MEM HWY STE V
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-4316
Practice Address - Country:US
Practice Address - Phone:757-596-5666
Practice Address - Fax:757-596-9755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
410000785Medicare PIN