Provider Demographics
NPI:1689617508
Name:WILLIAMS, BRUCE EDWARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E GOLF RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1250
Mailing Address - Country:US
Mailing Address - Phone:847-390-7666
Mailing Address - Fax:847-390-9345
Practice Address - Street 1:8120 GEORGIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6390
Practice Address - Country:US
Practice Address - Phone:847-390-7666
Practice Address - Fax:847-390-9345
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000747213E00000X
IL016004547213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004547Medicaid
IN100167720AMedicaid
INU28150Medicare UPIN
IL016004547Medicaid
IN1689617508OtherNPI