Provider Demographics
NPI:1437163532
Name:WILLIAMSON, THEODORE J (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:WILLIAMSON
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 391
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0391
Mailing Address - Country:US
Mailing Address - Phone:503-561-5135
Mailing Address - Fax:503-561-6807
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-435-6590
Practice Address - Fax:503-435-6591
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD115042085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236695Medicaid
C90957Medicare UPIN
ORR185914Medicare PIN
OR236695Medicaid