Basic Information
| Provider Information | |||||||||
| NPI: | 1770605677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FALCONWOOD CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339197535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583196 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583196 | ||||||||
| FaxNumber: | 2396583175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 06/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME29350 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 257304100 | 05 | FL | MEDICAID |