Provider Demographics
NPI:1629017108
Name:WILLIAMSON, JOHN ELLIS JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLIS
Last Name:WILLIAMSON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 DEER CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9013
Mailing Address - Country:US
Mailing Address - Phone:708-364-1253
Mailing Address - Fax:
Practice Address - Street 1:150 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1463
Practice Address - Country:US
Practice Address - Phone:815-942-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109152207P00000X
IL036-109152207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109152-1Medicaid
IL036109152-1Medicaid
ILL99157Medicare ID - Type Unspecified