Provider Demographics
NPI:1275502361
Name:MCWILLIAMS, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MCWILLIAMS
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 1:1310 W STEWART DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:
Practice Address - Street 1:18102 IRVINE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3402
Practice Address - Country:US
Practice Address - Phone:714-832-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA80152157OtherMC RAILROAD
CAWA062597AMedicare PIN
CA80152157OtherMC RAILROAD