Basic Information
| Provider Information | |||||||||
| NPI: | 1932192507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KIMIYO | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 216 MYSTIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689339 | ||||||||
| FaxNumber: | 9858689449 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 MYSTIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689339 | ||||||||
| FaxNumber: | 9858689449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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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 | 2080A0000X | 024151 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1489719 | 05 | LA | MEDICAID |