Provider Demographics
NPI:1003801622
Name:WILLIAMS, BRUCE R (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 NW MOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3096
Mailing Address - Country:US
Mailing Address - Phone:816-229-8187
Mailing Address - Fax:816-229-1181
Practice Address - Street 1:1509 NW MOCK AVE
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3096
Practice Address - Country:US
Practice Address - Phone:816-229-8187
Practice Address - Fax:816-229-1181
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO R9H16207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242574432Medicaid
KS100452270AMedicaid
KSN990185Medicare ID - Type Unspecified
MO242574432Medicaid