Provider Demographics
NPI:1780602011
Name:WILLIAMS-HOLLIDAY, CONSUELA MARIA (DPM)
Entity type:Individual
Prefix:MS
First Name:CONSUELA
Middle Name:MARIA
Last Name:WILLIAMS-HOLLIDAY
Suffix:
Gender:F
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 4124
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4124
Mailing Address - Country:US
Mailing Address - Phone:478-741-4332
Mailing Address - Fax:478-741-4343
Practice Address - Street 1:440 CHARTER BLVD
Practice Address - Street 2:STE 2202
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-0705
Practice Address - Country:US
Practice Address - Phone:478-741-4332
Practice Address - Fax:478-741-4343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD981213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA436532810BMedicaid
GAU94207Medicare UPIN
GA48SCCNLMedicare ID - Type Unspecified