Provider Demographics
NPI:1417986001
Name:WILLIAMS, MARK WAYNE SR (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:WILLIAMS
Suffix:SR
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-876-2293
Mailing Address - Fax:
Practice Address - Street 1:530 PARK AVE E STE 303
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3903
Practice Address - Country:US
Practice Address - Phone:815-872-9491
Practice Address - Fax:815-875-4060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL25609208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116745Medicaid