Provider Demographics
NPI:1942264114
Name:WILLIAMS, LARRY ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ROSS
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 1:995 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1210
Mailing Address - Country:US
Mailing Address - Phone:727-894-4738
Mailing Address - Fax:727-823-6710
Practice Address - Street 1:995 16TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1210
Practice Address - Country:US
Practice Address - Phone:727-894-4738
Practice Address - Fax:727-823-6710
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043000500Medicaid
FLD65382Medicare UPIN
FL62587Medicare ID - Type Unspecified