Provider Demographics
NPI:1760420012
Name:WILLIAMS, JASON R (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48514
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-8514
Mailing Address - Country:US
Mailing Address - Phone:913-248-9693
Mailing Address - Fax:913-248-9383
Practice Address - Street 1:700 W CENTRAL AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2184
Practice Address - Country:US
Practice Address - Phone:316-320-3100
Practice Address - Fax:316-321-2188
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-27831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7671123OtherAETNA
KS105442Medicare PIN
H18671Medicare UPIN