Provider Demographics
NPI:1447317722
Name:WILLIAMS, JERRY VALENTINE (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:VALENTINE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W ASCENSION ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2805
Mailing Address - Country:US
Mailing Address - Phone:225-647-9297
Mailing Address - Fax:225-647-3784
Practice Address - Street 1:317 W ASCENSION ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2805
Practice Address - Country:US
Practice Address - Phone:225-647-9297
Practice Address - Fax:225-647-3784
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB61552Medicare UPIN