Provider Demographics
NPI:1013784776
Name:WILLIAMS, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
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 68
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS REY
Mailing Address - State:CA
Mailing Address - Zip Code:92068-0068
Mailing Address - Country:US
Mailing Address - Phone:858-717-0328
Mailing Address - Fax:
Practice Address - Street 1:4109 VIA MAR
Practice Address - Street 2:
Practice Address - City:SAN LUIS REY
Practice Address - State:CA
Practice Address - Zip Code:92057
Practice Address - Country:US
Practice Address - Phone:619-949-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00074153246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy