Healthcare Provider Details

I. General information

NPI: 1982604369
Provider Name (Legal Business Name): ROY JEROME WILLIAMS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 UNION BLVD
SAINT LOUIS MO
63115-1127
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-261-4834
  • Fax: 314-383-3930
Mailing address:
  • Phone: 314-261-4834
  • Fax: 314-383-3930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR9968
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: