Provider Demographics
NPI:1093747297
Name:WILLIAMS, GARY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEAN
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 1:2520 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3130
Mailing Address - Country:US
Mailing Address - Phone:318-212-5040
Mailing Address - Fax:318-212-5045
Practice Address - Street 1:2520 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 202
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3130
Practice Address - Country:US
Practice Address - Phone:318-212-5040
Practice Address - Fax:318-212-5045
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06590R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1339482Medicaid
LA5H721C731Medicare PIN
LA5H721Medicare PIN
LA1339482Medicaid