Provider Demographics
NPI:1063684868
Name:WILLIAMS, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18701 OLD HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069
Mailing Address - Country:US
Mailing Address - Phone:636-257-3322
Mailing Address - Fax:636-257-8026
Practice Address - Street 1:18701 OLD HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069-3526
Practice Address - Country:US
Practice Address - Phone:636-257-3322
Practice Address - Fax:636-257-8026
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36324302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization