Provider Demographics
NPI:1992231633
Name:WILLIAMS, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WILLIAMS
Suffix:
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 1:8590 PRODUCTION AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2281
Mailing Address - Country:US
Mailing Address - Phone:866-632-2823
Mailing Address - Fax:866-463-8141
Practice Address - Street 1:8590 PRODUCTION AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2281
Practice Address - Country:US
Practice Address - Phone:866-632-2823
Practice Address - Fax:866-463-8141
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA986938171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor