Provider Demographics
NPI: | 1518076660 |
---|---|
Name: | WILLIAMS, RANDALL P (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | RANDALL |
Middle Name: | P |
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: | 146 MEDICAL PARK RD |
Mailing Address - Street 2: | STE 108 |
Mailing Address - City: | MOORESVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28117-8529 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-662-0877 |
Mailing Address - Fax: | 704-662-0875 |
Practice Address - Street 1: | 146 MEDICAL PARK RD STE 108 |
Practice Address - Street 2: | |
Practice Address - City: | MOORESVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28117-8529 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-662-0877 |
Practice Address - Fax: | 704-662-0875 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-30 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 36454 | 207L00000X, 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 87895 | Other | BCBS |
NC | 8987895 | Medicaid | |
NC | BW3480352 | Other | DEA |
NC | 8987895 | Medicaid | |
NC | F58478 | Medicare UPIN |