Healthcare Provider Details

I. General information

NPI: 1366707580
Provider Name (Legal Business Name): JOHN D WILLIAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S MAIN ST
MIDDLETOWN CT
06457-3649
US

IV. Provider business mailing address

90 S MAIN ST
MIDDLETOWN CT
06457-3649
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6486
  • Fax:
Mailing address:
  • Phone: 860-358-6300
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number55047
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number055047
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: