Provider Demographics
NPI:1053508176
Name:GREGORY G WILLIAMS MD INC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GREGORY G WILLIAMS MD INC A MEDICAL CORPORATION
Other - Org Name:SOUTH VALLEY VEIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-654-8346
Mailing Address - Street 1:1500 HAGGIN OAKS BLVD
Mailing Address - Street 2:202
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-1333
Mailing Address - Country:US
Mailing Address - Phone:661-654-8346
Mailing Address - Fax:661-654-8337
Practice Address - Street 1:1500 HAGGIN OAKS BLVD
Practice Address - Street 2:202
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-1333
Practice Address - Country:US
Practice Address - Phone:661-654-8346
Practice Address - Fax:661-654-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73172261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699795088OtherTYPE 1 NPI
1699795088OtherTYPE 1 NPI