Provider Demographics
NPI:1134594369
Name:WILLIAMSON, REGINALD LAMONT
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:LAMONT
Last Name:WILLIAMSON
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 1:12923 S PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7442
Mailing Address - Country:US
Mailing Address - Phone:773-405-8996
Mailing Address - Fax:773-468-7918
Practice Address - Street 1:12923 S PARNELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7442
Practice Address - Country:US
Practice Address - Phone:773-405-8996
Practice Address - Fax:773-468-7918
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW45273274015172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver