| Entity Name: | MARK M. WILLIAMS, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 24 Mar 1998 (27 years ago) |
| Document Number: | P98000028241 |
| FEI/EIN Number | 593501407 |
| Address: | 21c Orinda Way, Orinda, CA, 94563, US |
| Mail Address: | 21c Orinda Way, Orinda, CA, 94563, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457547523 | 2007-09-21 | 2020-02-01 | 2202 COUNTRY CLUB DR, LYNN HAVEN, FL, 324441992, US | 2202 COUNTRY CLUB DR, LYNN HAVEN, FL, 324441992, US | |||||||||||||||||||||||||||
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| Phone | +1 850-769-2757 |
| Fax | 8883748684 |
| Phone | +1 850-381-1010 |
Authorized person
| Name | DR. MARK M WILLIAMS |
| Role | PRESIDENT |
| Phone | 8507692757 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME0057987 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 372895100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| TAYLOR CHUCK | Agent | 2589 JENKS AVENUE, PANAMA CITY, FL, 32405 |
| Name | Role | Address |
|---|---|---|
| Williams Mark MDr. | President | 21C Orinda Way, #367, Orinda, CA, 94563 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000042049 | WILLIAMS SHOULDER AND SPORTS MEDICINE | EXPIRED | 2016-04-26 | 2021-12-31 | No data | 320 EAST 19TH STREET, PANAMA CITY, FL, 32405 |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
