Provider Demographics
NPI:1376504647
Name:WILLIAMS, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
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:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0648
Mailing Address - Country:US
Mailing Address - Phone:912-245-4179
Mailing Address - Fax:912-403-3346
Practice Address - Street 1:1604 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8914
Practice Address - Country:US
Practice Address - Phone:912-245-4179
Practice Address - Fax:912-403-3346
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38650208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00600575CMedicaid
GA000600575FMedicaid
GAF24920Medicare UPIN
GA0816G024Medicare Oscar/Certification
GA02BDCJQMedicare ID - Type Unspecified
GA00600575CMedicaid