Provider Demographics
NPI:1477554624
Name:WILLIAMS, MARK STANLEY (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STANLEY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 LOWS ROAD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815
Mailing Address - Country:US
Mailing Address - Phone:570-784-7300
Mailing Address - Fax:570-784-7331
Practice Address - Street 1:6850 LOWS RD
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8729
Practice Address - Country:US
Practice Address - Phone:570-784-7300
Practice Address - Fax:570-784-7331
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05008141L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016392810001Medicaid
PA902260M0AMedicare PIN
G49397Medicare UPIN