Provider Demographics
NPI:1598161192
Name:WILLIAMS, MICHAEL ROY (RD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1513
Mailing Address - Country:US
Mailing Address - Phone:616-375-6083
Mailing Address - Fax:
Practice Address - Street 1:515 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1513
Practice Address - Country:US
Practice Address - Phone:616-375-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0401-001HMedicaid