Provider Demographics
NPI:1619125952
Name:WILLIAMS, OTHA EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:OTHA
Middle Name:EDWARD
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1736 LAKE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3353
Mailing Address - Country:US
Mailing Address - Phone:601-624-4311
Mailing Address - Fax:601-321-9519
Practice Address - Street 1:1736 LAKE TRACE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3353
Practice Address - Country:US
Practice Address - Phone:601-624-4311
Practice Address - Fax:601-321-9519
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS07230208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS021948391Medicare PIN