Healthcare Provider Details

I. General information

NPI: 1245253814
Provider Name (Legal Business Name): MYRIA A MACK-WILLIAMS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 W 11TH AVE
COVINGTON LA
70433-2318
US

IV. Provider business mailing address

728 W 11TH AVE
COVINGTON LA
70433-2318
US

V. Phone/Fax

Practice location:
  • Phone: 985-893-3395
  • Fax:
Mailing address:
  • Phone: 985-893-3395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC1-0005655
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-427421
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD 205223
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: