Provider Demographics
NPI:1720838873
Name:WILLIAMS, WALTER KEANDRE DESEAN IV (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:KEANDRE DESEAN
Last Name:WILLIAMS
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:WALT
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:519 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3620
Mailing Address - Country:US
Mailing Address - Phone:812-948-0616
Mailing Address - Fax:
Practice Address - Street 1:519 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3620
Practice Address - Country:US
Practice Address - Phone:812-948-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004506A152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program