Provider Demographics
NPI:1851496392
Name:WILLIAMS, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-446-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36453208800000X, 2088P0231X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4038478OtherBLUE CROSS/BLUE SHIELD
1900064OtherUNITED HEALTHCARE
SCNC 2863Medicaid
TN22876Medicaid
AR5AG24Medicaid
TN128654Medicaid
1599052-009OtherCIGNA HEALTHCARE
NC1851496392Medicaid
7343762OtherAETNA INSURANCE
SCNC 2863Medicaid
TN4038478OtherBLUE CROSS/BLUE SHIELD
TN128654Medicaid