Provider Demographics
NPI:1861616955
Name:WILL, JERRY P SR (DISPENSING OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:P
Last Name:WILL
Suffix:SR
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 B COLLEGE HIGHWAY
Mailing Address - Street 2:SOUTHAMPTON OPTICAL
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073
Mailing Address - Country:US
Mailing Address - Phone:413-527-5613
Mailing Address - Fax:413-527-3526
Practice Address - Street 1:15 B COLLEGE HIGHWAY
Practice Address - Street 2:15 B SOUTHAMPTON OPTICAL
Practice Address - City:SOUTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01073
Practice Address - Country:US
Practice Address - Phone:413-527-5613
Practice Address - Fax:413-527-3526
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA4110156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0313033Medicaid
688428Medicare UPIN
MA0313033Medicaid