Provider Demographics
NPI:1710086749
Name:WILLIAMS, JERRY K JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:K
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3861
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-6861
Mailing Address - Country:US
Mailing Address - Phone:505-426-1200
Mailing Address - Fax:505-426-1202
Practice Address - Street 1:2301 7TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4966
Practice Address - Country:US
Practice Address - Phone:505-426-1200
Practice Address - Fax:505-426-1202
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-1672084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201311184OtherTAX ID
NM23432Medicaid
NM201047864OtherPHP & SALUD
NM00NM009T07OtherBCBS
NMC100521093OtherUNITED AMERICAN
NMNM9999OtherMUTUAL OF OMAHA
NM201311184OtherTAX ID
NM23432Medicaid
NMF23565Medicare UPIN