Basic Information
Provider Information
NPI: 1003801622
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILLIAMS
FirstName: BRUCE
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1509 NW MOCK AVE
Address2:  
City: BLUE SPRINGS
State: MO
PostalCode: 640153096
CountryCode: US
TelephoneNumber: 8162298187
FaxNumber: 8162291181
Practice Location
Address1: 1509 NW MOCK AVE
Address2:  
City: BLUE SPRINGS
State: MO
PostalCode: 640153096
CountryCode: US
TelephoneNumber: 8162298187
FaxNumber: 8162291181
Other Information
ProviderEnumerationDate: 09/20/2005
LastUpdateDate: 12/21/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XDO R9H16MOY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
100452270A05KS MEDICAID
24257443205MO MEDICAID


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