Provider Demographics
NPI:1861459380
Name:WILLIAMSON, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:WILLIAMSON
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 1:135 W RAVINE RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3847
Mailing Address - Country:US
Mailing Address - Phone:423-246-7372
Mailing Address - Fax:423-578-4369
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-246-7372
Practice Address - Fax:423-578-4369
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26502207W00000X
TN47442207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531153Other2ND BLUE CROSS PROVIDER #
AL51002085OtherBCBSAL MAIN PROVIDER #
AL009933593Medicaid
AL051556533Medicaid
TN103I187234Medicare PIN
AL009933593Medicaid