Provider Demographics
NPI:1245201557
Name:WILLIAMS, JOHNATHAN DELEON (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:DELEON
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHNATHAN
Other - Middle Name:D
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:640 SUMMIT CROSSING PL
Mailing Address - Street 2:STE 204
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2142
Mailing Address - Country:US
Mailing Address - Phone:704-865-0626
Mailing Address - Fax:704-865-6531
Practice Address - Street 1:640 SUMMIT CROSSING PL
Practice Address - Street 2:STE 204
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2142
Practice Address - Country:US
Practice Address - Phone:704-865-0626
Practice Address - Fax:704-865-6531
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31957207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8987659Medicaid
NC8987659Medicaid
NC2160951FMedicare PIN