Provider Demographics
NPI:1851353247
Name:WILLIAMS, MICHAEL L (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3026 WINGHAVEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-333-9820
Mailing Address - Fax:636-228-0039
Practice Address - Street 1:ULTRA WELLNESS MEDICAL, LLC
Practice Address - Street 2:3026 WINGHAVEN BLVD.
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-333-9820
Practice Address - Fax:636-228-0039
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A18065207Q00000X
IL2005036219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200202505Medicaid