Healthcare Provider Details

I. General information

NPI: 1932779782
Provider Name (Legal Business Name): WILLIAMS MEDICAL GROUP PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N 14TH ST
PONCA CITY OK
74601-1734
US

IV. Provider business mailing address

701 CEDAR LAKE BLVD STE 120
OKLAHOMA CITY OK
73114-7815
US

V. Phone/Fax

Practice location:
  • Phone: 580-749-5516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRANT ASAY
Title or Position: CEO
Credential:
Phone: 405-445-1210