Basic Information
| Provider Information | |||||||||
| NPI: | 1700880358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | CAROLYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363794140 | ||||||||
| FaxNumber: | 6363794132 | ||||||||
| Practice Location | |||||||||
| Address1: | 3449 PHEASANT MEADOW DR | ||||||||
| Address2: | STE 107 | ||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633687364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363794140 | ||||||||
| FaxNumber: | 6363794132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 03/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2001026591 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204028005 | 05 | MO | MEDICAID |