Provider Demographics
NPI:1154302602
Name:WILLIAMSON, JEFFREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:WILLIAMSON
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 1:900 MAIN ST
Mailing Address - Street 2:SUITE 530
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-672-5975
Mailing Address - Fax:309-655-1678
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 530
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-672-5975
Practice Address - Fax:309-655-1678
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066240208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360662401Medicaid
D16776Medicare UPIN
IL0360662401Medicaid