Provider Demographics
NPI:1245559186
Name:WILLIAMS, THOMAS JACKIE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACKIE
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 1:7611 BLUE FOX RUN
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-6337
Mailing Address - Country:US
Mailing Address - Phone:513-777-4411
Mailing Address - Fax:
Practice Address - Street 1:7611 BLUE FOX RUN
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6337
Practice Address - Country:US
Practice Address - Phone:513-777-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35025961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE77262Medicare UPIN