Provider Demographics
NPI:1669488003
Name:WILLIAMS, MALLORY (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20060-0001
Mailing Address - Country:US
Mailing Address - Phone:202-865-6679
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW STE 4000
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-4228
Practice Address - Country:US
Practice Address - Phone:202-865-3785
Practice Address - Fax:202-865-3136
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227496208600000X
OH35.095349208600000X
DCMD041969208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1184071Medicaid
DC086515600Medicaid