Provider Demographics
NPI:1629692801
Name:WILLIAMS, THEODORE IV
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:WILLIAMS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3628
Mailing Address - Country:US
Mailing Address - Phone:216-513-3249
Mailing Address - Fax:
Practice Address - Street 1:1371 VICTORY DR
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3628
Practice Address - Country:US
Practice Address - Phone:216-513-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid