Provider Demographics
NPI:1972697746
Name:WILLIAMS, JOHNNY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:LEE
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:PO BOX 12033
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-2033
Mailing Address - Country:US
Mailing Address - Phone:910-333-0551
Mailing Address - Fax:910-938-0900
Practice Address - Street 1:825 GUM BRANCH RD
Practice Address - Street 2:SUITE 121
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6298
Practice Address - Country:US
Practice Address - Phone:910-333-0551
Practice Address - Fax:910-938-0900
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20584207VG0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC87700OtherBCBSNC
NC0728888OtherUNITED HEALTHCARE
NC8987700Medicaid
NC20584OtherMEDICAL LICENSE
NC34D0944653OtherCLIA
NC34D0944653OtherCLIA
NC87700OtherBCBSNC
NC34D0944653OtherCLIA
NC202720-AMedicare ID - Type Unspecified