Provider Demographics
NPI:1699273201
Name:WILLIAMS, GORNIE THOMAS JR
Entity type:Individual
Prefix:MR
First Name:GORNIE
Middle Name:THOMAS
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 S IRONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7656
Mailing Address - Country:US
Mailing Address - Phone:918-237-9909
Mailing Address - Fax:
Practice Address - Street 1:1055 S HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9043
Practice Address - Country:US
Practice Address - Phone:918-947-4203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator