Provider Demographics
NPI:1235478728
Name:WILLIAMS, GREGORY A (IDC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 FLYNN RD APT 5106
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5818
Mailing Address - Country:US
Mailing Address - Phone:360-929-0074
Mailing Address - Fax:
Practice Address - Street 1:2600 DODSON ST STE 3
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4432
Practice Address - Country:US
Practice Address - Phone:805-982-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman