Provider Demographics
NPI:1194804377
Name:ODNEAL, WILLIAM J
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:ODNEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-1520
Mailing Address - Country:US
Mailing Address - Phone:573-883-2774
Mailing Address - Fax:573-883-9087
Practice Address - Street 1:466 MARKET ST
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1520
Practice Address - Country:US
Practice Address - Phone:573-883-2774
Practice Address - Fax:573-883-9087
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310040316Medicaid
MO108009OtherOPTOMETRY
MO000006657Medicare PIN
MOT42598Medicare UPIN
MO108009OtherOPTOMETRY