Provider Demographics
NPI:1922212117
Name:WILLIAMS, JEREMY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SCOTT
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 1:1 GARTON PLZ
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-2128
Mailing Address - Country:US
Mailing Address - Phone:304-517-1301
Mailing Address - Fax:304-517-1304
Practice Address - Street 1:1 GARTON PLZ
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-2128
Practice Address - Country:US
Practice Address - Phone:304-517-1301
Practice Address - Fax:304-517-1304
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7400611OtherMEDICARE PTAN
WV3810015258Medicaid