Provider Demographics
NPI:1558549147
Name:JOHN T WILLIAMS
Entity Type:Organization
Organization Name:JOHN T WILLIAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-792-6066
Mailing Address - Street 1:16 E FERN AVE
Mailing Address - Street 2:STE A
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4000
Mailing Address - Country:US
Mailing Address - Phone:909-792-6066
Mailing Address - Fax:909-792-4424
Practice Address - Street 1:16 E FERN AVE
Practice Address - Street 2:STE A
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4000
Practice Address - Country:US
Practice Address - Phone:909-792-6066
Practice Address - Fax:909-792-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2635213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E26352Medicaid
CAT11413Medicare UPIN
CA000E26352Medicaid
CA4540130001Medicare NSC