Provider Demographics
NPI:1053368357
Name:WILLIAMS, TINA V (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:V
Last Name:WILLIAMS
Suffix:
Gender:F
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:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-903-0134
Mailing Address - Fax:770-903-0135
Practice Address - Street 1:6330 PRIMROSE HILL CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4544
Practice Address - Country:US
Practice Address - Phone:770-903-0134
Practice Address - Fax:770-903-0135
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1609816123OtherGEORGIA CLINIC, PC GROUP NPI #
GA000731959AMedicaid
GAGRP2768Medicare PIN
D50550Medicare UPIN
GA000731959AMedicaid