Provider Demographics
NPI:1417990045
Name:WILLIAMS, PHILIP D (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
Last Name:WILLIAMS
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:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-0024
Mailing Address - Country:US
Mailing Address - Phone:541-735-9420
Mailing Address - Fax:541-747-9870
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-735-9420
Practice Address - Fax:541-747-9870
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23771207R00000X
CT0472772084P0804X
CAC552552084P0804X
OR1659482084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH37691Medicare UPIN