Provider Demographics
NPI:1508054123
Name:WILLIAMS, KWAME A (DPM)
Entity Type:Individual
Prefix:
First Name:KWAME
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DPM
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 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-626-6161
Mailing Address - Fax:419-502-3511
Practice Address - Street 1:1265 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4004
Practice Address - Country:US
Practice Address - Phone:330-758-8808
Practice Address - Fax:330-758-4288
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003472213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2819801Medicaid
OH4220893Medicare PIN
OH4220892Medicare PIN
OH2819801Medicaid