Provider Demographics
NPI:1538291737
Name:WILLIAMS, MARK THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 WATERVLIET AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2705
Mailing Address - Country:US
Mailing Address - Phone:937-256-2292
Mailing Address - Fax:937-256-9905
Practice Address - Street 1:1219 WATERVLIET AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2705
Practice Address - Country:US
Practice Address - Phone:937-256-2292
Practice Address - Fax:937-256-9905
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000000568OtherANTHEM COMMUNITY INS CO
OH0875423Medicaid
OHWI0660961Medicare ID - Type Unspecified
OHU16760Medicare UPIN