Healthcare Provider Details

I. General information

NPI: 1861912669
Provider Name (Legal Business Name): NICHOLAS MARC WILLIAMS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

2534 S KINNICKINNIC AVE STE 207
MILWAUKEE WI
53207-1608
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1000
  • Fax:
Mailing address:
  • Phone: 330-241-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number18159-875
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: