Provider Demographics
NPI:1174605620
Name:WILLIAMS, EVAN GRANT (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:GRANT
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 1:1101 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1921
Mailing Address - Country:US
Mailing Address - Phone:573-756-6751
Mailing Address - Fax:
Practice Address - Street 1:1101 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-756-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28008207R00000X, 208000000X, 208M00000X
MO2019009758208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC280083Medicaid
SCAA81637951Medicare PIN