Provider Demographics
NPI:1225655897
Name:WILLIAMS, OMAR S
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 STRICKLAND RD STE 103-142
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-1902
Mailing Address - Country:US
Mailing Address - Phone:919-870-1272
Mailing Address - Fax:
Practice Address - Street 1:212 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8775
Practice Address - Country:US
Practice Address - Phone:919-870-1272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8230102172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver