Provider Demographics
NPI:1780882290
Name:DR JERRY V WILLIAMS A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:DR JERRY V WILLIAMS A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:V
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:225-647-9297
Mailing Address - Street 1:317 W ASCENSION ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2805
Mailing Address - Country:US
Mailing Address - Phone:225-647-9297
Mailing Address - Fax:225-647-3784
Practice Address - Street 1:317 W ASCENSION ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2805
Practice Address - Country:US
Practice Address - Phone:225-647-9297
Practice Address - Fax:225-647-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1347353Medicaid
LA5D321Medicare PIN
LAB61552Medicare UPIN