Provider Demographics
NPI:1598975138
Name:WILLIAMS, JEANETTE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MICHELLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 ILO LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-2519
Mailing Address - Country:US
Mailing Address - Phone:415-350-2021
Mailing Address - Fax:
Practice Address - Street 1:913 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1433
Practice Address - Country:US
Practice Address - Phone:707-942-6233
Practice Address - Fax:707-942-6382
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44868207Q00000X
CAC52939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN549196700Medicaid
MNH67718Medicare UPIN
MN080013131Medicare ID - Type Unspecified