Provider Demographics
NPI:1598755001
Name:WILLIAMS, SALLY A (DO)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2108
Mailing Address - Country:US
Mailing Address - Phone:605-322-3241
Mailing Address - Fax:
Practice Address - Street 1:1000 E 23RD ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2108
Practice Address - Country:US
Practice Address - Phone:605-322-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46021207Q00000X
SD8912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43510400Medicaid
SD5605850Medicaid
WI0639 20195Medicare PIN
WI43510400Medicaid
SD5605850Medicaid