Provider Demographics
NPI:1528443199
Name:WYATT WILLIAMS O.D. INC
Entity type:Organization
Organization Name:WYATT WILLIAMS O.D. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-207-0700
Mailing Address - Street 1:17900 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5494
Mailing Address - Country:US
Mailing Address - Phone:918-207-0700
Mailing Address - Fax:918-207-0211
Practice Address - Street 1:17900 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5494
Practice Address - Country:US
Practice Address - Phone:918-207-0700
Practice Address - Fax:918-207-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty