Healthcare Provider Details

I. General information

NPI: 1104494798
Provider Name (Legal Business Name): KENDRICK J WILLIAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE SAINT LOUIS MO
63367-1366
US

IV. Provider business mailing address

1205 FOXVIEW TER
BALLWIN MO
63011-4315
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022039727
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: