Provider Demographics
NPI:1225014632
Name:WILLIAMS, REGINALD GAYLORD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:GAYLORD
Last Name:WILLIAMS
Suffix:JR
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:94180 2ND ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8733
Practice Address - Country:US
Practice Address - Phone:541-247-7047
Practice Address - Fax:541-247-0123
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC GROUP NPI NUMBER
OR214296Medicaid
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR110074859OtherRR MEDICARE PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR383853Medicare Oscar/Certification
OR0577260001Medicare NSC
ORR111971Medicare PIN
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER