Provider Demographics
NPI:1629143144
Name:WILLIAMS, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1065 BUCKS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-9507
Mailing Address - Country:US
Mailing Address - Phone:530-283-2121
Mailing Address - Fax:530-283-7953
Practice Address - Street 1:803 S PONDEROSA ST
Practice Address - Street 2:SUITE C
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5521
Practice Address - Country:US
Practice Address - Phone:928-472-1222
Practice Address - Fax:928-472-1213
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ29945208600000X, 2086S0127X
CAG88791208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ646490Medicaid
AZ646490Medicaid
E89233Medicare UPIN