Provider Demographics
NPI:1003822123
Name:WILLIAMS, JOHN K (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:K
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1102 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3503
Mailing Address - Country:US
Mailing Address - Phone:417-347-1213
Mailing Address - Fax:417-347-6266
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-1213
Practice Address - Fax:417-347-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4J122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203020441Medicaid
E61046Medicare UPIN
MO203020441Medicaid