Provider Demographics
NPI:1275166514
Name:WILLIAMS, IRA LEE
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:LEE
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 1:9801 S KARLOV AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3443
Mailing Address - Country:US
Mailing Address - Phone:773-593-5805
Mailing Address - Fax:
Practice Address - Street 1:9801 S KARLOV AVE APT 203
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3443
Practice Address - Country:US
Practice Address - Phone:773-593-5805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
W45241279266347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle