Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | DO R9H16 | MO |
NPI | 1003801622 |
---|---|
Provider Name | Bruce R Williams |
First Address | Blue Springs, MO 64015-3096 |
Second Address | Blue Springs, MO 64015-3096 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2005 |
Last Update Date | 21/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100452270A | (05) | KS |
242574432 | (05) | MO |
E65121 | (02) | MO |