Healthcare Provider Details

I. General information

NPI: 1336170869
Provider Name (Legal Business Name): MARK DWIGHT WILLIAMS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 WILSON DR. NMCSD, ATTN: MEDICAL STAFF, SERVICES
SAN DIEGO CA
92134
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6460
  • Fax: 619-532-6299
Mailing address:
  • Phone: 619-532-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA80386
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA80386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: