Provider Demographics
NPI:1932106713
Name:WILLIAMS, DOUGLAS STANLEY (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STANLEY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1702
Mailing Address - Country:US
Mailing Address - Phone:208-785-6700
Mailing Address - Fax:208-785-6767
Practice Address - Street 1:9 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1702
Practice Address - Country:US
Practice Address - Phone:208-785-6700
Practice Address - Fax:208-785-6767
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD176R213ES0103X
IDP-156213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804309300Medicaid
IDP1571OtherBLUE CROSS
ID341488OtherDMBA
ID480034721OtherMEDICARE RAILROAD
ID000010015672OtherBLUE SHIELD
ID461973001OtherDMERC
ID1285947705Medicare NSC
ID480034721OtherMEDICARE RAILROAD
IDU68442Medicare UPIN