Provider Demographics
NPI:1669575478
Name:WILLIAMS, MARK RICHARD (DPM)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
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:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423
Mailing Address - Country:US
Mailing Address - Phone:810-653-9060
Mailing Address - Fax:810-658-2248
Practice Address - Street 1:605 S STATE ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423
Practice Address - Country:US
Practice Address - Phone:810-653-9060
Practice Address - Fax:810-658-2248
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW001983213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4632598Medicaid
MIU72426Medicare UPIN
MION88250Medicare PIN
MI5157260001Medicare NSC