Provider Demographics
NPI:1245253814
Name:MACK-WILLIAMS, MYRIA A (MD)
Entity type:Individual
Prefix:DR
First Name:MYRIA
Middle Name:A
Last Name:MACK-WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 W 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2318
Mailing Address - Country:US
Mailing Address - Phone:985-893-3395
Mailing Address - Fax:
Practice Address - Street 1:728 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2318
Practice Address - Country:US
Practice Address - Phone:985-893-3395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0005655208000000X
PAMD-427421208000000X
LAMD 205223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000961001Medicaid
DE0000961001Medicaid