MEDICARE: DR. JUAN DEON WILLIAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant	BA11300072	IN

General Provider Information

NPI Number	:	1003542937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN DEON WILLIAMS

Provider Business Mailing Address
First Line	:	817 E BERRY ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-3905
Country	:	US
Telephone Number	:	260-418-6528
Fax Number	:

Provider Business Practice Location Address
First Line	:	2843 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-750-2889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	07/25/2022

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