Provider Demographics
NPI:1912120080
Name:WILLIAMS, PHILLIP A (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9693
Mailing Address - Country:US
Mailing Address - Phone:662-287-1061
Mailing Address - Fax:
Practice Address - Street 1:2301 S HARPER RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6771
Practice Address - Country:US
Practice Address - Phone:662-287-1297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880081Medicaid