Provider Demographics
NPI:1174692891
Name:WILLIAMS, REGINALD A (MD)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-0467
Mailing Address - Country:US
Mailing Address - Phone:912-427-9169
Mailing Address - Fax:912-427-9171
Practice Address - Street 1:113 COLONIAL WAY
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0245
Practice Address - Country:US
Practice Address - Phone:912-427-9169
Practice Address - Fax:912-427-9171
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY37487208600000X
GA055788208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061377Medicaid
KYH73308Medicare UPIN