Provider Demographics
NPI:1093873721
Name:WILLIAMS, KIMBERLY (DPM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:WESLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:5701 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-2617
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:5701 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-2617
Practice Address - Country:US
Practice Address - Phone:314-367-7848
Practice Address - Fax:314-367-2985
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1623213EP1101X
MO2013007946213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1539371-01Medicaid
TX1539371-01Medicaid