Provider Demographics
NPI:1780661074
Name:WILLIAMS, JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006949W207Q00000X
IN02002139A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201219650Medicaid
CA1586OtherGROUP MEDICARE RAILROAD
OH0989499OtherGROUP MEDICAID
0110615OtherUHC PIN
000000185151OtherANTHEM PIN
080157683OtherMEDICARE RAILROAD
OH2187011Medicaid
311413469041OtherCARESOURCE PIN
000000177576OtherUNISON PIN
IN000000873283OtherANTHEM PROVIDER NUMBER
IN815500060Medicare PIN
OHWI0862319Medicare PIN
INP01365995Medicare PIN
080157683OtherMEDICARE RAILROAD
OH2187011Medicaid