Basic Information
| Provider Information | |||||||||
| NPI: | 1992759641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1029 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514545 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Practice Location | |||||||||
| Address1: | 1029 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514545 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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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 | 207W00000X | 27423 | KY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 64274236 | 05 | KY | MEDICAID | 000000207063 | 01 | KY | ANTHEM | OTHER |