Provider Demographics
NPI:1851480974
Name:WILLIAMS, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 J M ASH DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-3238
Mailing Address - Country:US
Mailing Address - Phone:662-252-1599
Mailing Address - Fax:662-252-1986
Practice Address - Street 1:1938 CRESCENT MEADOW DRIVE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3238
Practice Address - Country:US
Practice Address - Phone:662-252-1599
Practice Address - Fax:662-252-1986
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0011155Medicaid
MS0011155Medicaid
MS110001832Medicare PIN