Healthcare Provider Details

I. General information

NPI: 1629238787
Provider Name (Legal Business Name): KELLIE NICOLE WILLIAMS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE NICOLE GOFORTH M.D.

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SANTA ROSA
SAN ANTONIO TX
78207-3108
US

IV. Provider business mailing address

315 N SAN SABA STE 1135
SAN ANTONIO TX
78207-3255
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-3030
  • Fax:
Mailing address:
  • Phone: 210-704-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ3465
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number0101249447
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: