Provider Demographics
NPI:1164303202
Name:WILLIAMS, DEMARCO
Entity type:Individual
Prefix:
First Name:DEMARCO
Middle Name:
Last Name:WILLIAMS
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 1:1827 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-3547
Mailing Address - Country:US
Mailing Address - Phone:502-963-5792
Mailing Address - Fax:502-653-7063
Practice Address - Street 1:1827 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3547
Practice Address - Country:US
Practice Address - Phone:502-963-5792
Practice Address - Fax:502-653-7063
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty