Provider Demographics
NPI:1346347242
Name:WILLIAMS, ROGER D (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:ZABLOCKI VA MEDICAL CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-0001
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:ZABLOCKI VA MEDICAL CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR983P103G00000X
WI3042103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR990007081OtherRAILROAD MEDICARE
AR50874000010OtherQUALCHOICE
AR133649719Medicaid
AR5T814OtherBLUE CROSS
AR983POtherCHAMPUS
AR5T8146884Medicare ID - Type Unspecified
ARR34363Medicare UPIN
WI736012586Medicare PIN
WI680862574Medicare PIN