Provider Demographics
NPI:1932393220
Name:WILLIAMS, TOM ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:ELLIS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-428-1330
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:619-428-1330
Practice Address - Fax:619-428-7952
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine