Healthcare Provider Details

I. General information

NPI: 1225655897
Provider Name (Legal Business Name): MR. OMAR S WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 ACADEMY DR
GREENVILLE NC
27834-8775
US

IV. Provider business mailing address

9650 STRICKLAND RD STE 103-142
RALEIGH NC
27615-1902
US

V. Phone/Fax

Practice location:
  • Phone: 919-870-1272
  • Fax:
Mailing address:
  • Phone: 919-870-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number8230102
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: