Basic Information
Provider Information | |||||||||
NPI: | 1932116209 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | MISTY | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2415 PARKWOOD DR. | ||||||||
Address2: |   | ||||||||
City: | BRUNSWICK | ||||||||
State: | GA | ||||||||
PostalCode: | 31520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432373378 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Practice Location | |||||||||
Address1: | 2415 PARKWOOD DR. | ||||||||
Address2: |   | ||||||||
City: | BRUNSWICK | ||||||||
State: | GA | ||||||||
PostalCode: | 31520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124667188 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 04/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0064741 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 063051 | GA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 411055200 | 05 | MD |   | MEDICAID | 89031201 | 01 | MD | BCBS | OTHER | 0024 | 01 | DC | BCBS | OTHER | P00341246 | 01 | MD | RAILROAD MEDICARE | OTHER | 3810005966 | 05 | WV |   | MEDICAID |