Healthcare Provider Details

I. General information

NPI: 1710086749
Provider Name (Legal Business Name): JERRY K WILLIAMS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 7TH ST SUITE B
LAS VEGAS NM
87701-4966
US

IV. Provider business mailing address

PO BOX 3861
LAS VEGAS NM
87701-6861
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-1200
  • Fax: 505-426-1202
Mailing address:
  • Phone: 505-426-1200
  • Fax: 505-426-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number94-167
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: