Provider Demographics
NPI:1750446217
Name:WILLIAMSON, MALCOLM EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:EDWARD
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:8432 THORNTREE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138
Mailing Address - Country:US
Mailing Address - Phone:734-675-3319
Mailing Address - Fax:734-692-5061
Practice Address - Street 1:8432 THORNTREE DRIVE
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138
Practice Address - Country:US
Practice Address - Phone:734-675-3319
Practice Address - Fax:734-692-5061
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005793207RE0101X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1296713Medicaid
MI5823063OtherBCBS
MI5823063OtherBCBS