Provider Demographics
NPI:1700880358
Name:WILLIAMSON, HEATHER CAROLYN (DO)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:CAROLYN
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:636-379-4140
Mailing Address - Fax:636-379-4132
Practice Address - Street 1:3449 PHEASANT MEADOW DR
Practice Address - Street 2:STE 107
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7364
Practice Address - Country:US
Practice Address - Phone:636-379-4140
Practice Address - Fax:636-379-4132
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001026591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204028005Medicaid
908714095Medicare ID - Type Unspecified
MO908714748Medicare PIN
MO204028005Medicaid
H97226Medicare UPIN