Provider Demographics
NPI:1871191817
Name:WILLIAMS, JEREMY VINCENT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:VINCENT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2031
Mailing Address - Country:US
Mailing Address - Phone:504-495-5844
Mailing Address - Fax:
Practice Address - Street 1:7023 READ LN
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-2366
Practice Address - Country:US
Practice Address - Phone:504-244-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7143122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7143OtherPRIVATE INSURANCE
LA7143Medicaid