Provider Demographics
NPI:1407470214
Name:W. WALLACE WEBSTER MD LLC
Entity Type:Organization
Organization Name:W. WALLACE WEBSTER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:541-297-5342
Mailing Address - Street 1:620 COMMERCIAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1846
Mailing Address - Country:US
Mailing Address - Phone:541-297-5342
Mailing Address - Fax:541-808-0415
Practice Address - Street 1:620 COMMERCIAL AVE STE A
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1846
Practice Address - Country:US
Practice Address - Phone:541-297-5342
Practice Address - Fax:541-808-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274244Medicaid