Provider Demographics
NPI:1881641165
Name:WILLIAMSON, JEFFREY R (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:DO
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 260
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-884-5191
Mailing Address - Fax:616-884-5192
Practice Address - Street 1:6785 MYERS LAKE AVE NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341
Practice Address - Country:US
Practice Address - Phone:616-884-5191
Practice Address - Fax:616-884-5192
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW011762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI48103028Medicaid
MICC11129554471Medicare Oscar/Certification
MIOP23710Medicare ID - Type Unspecified
MI48103028Medicaid