Provider Demographics
NPI:1558523514
Name:WILLIAMS, MATTHEW (LMT IASI)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMT IASI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19434 SW HOLLYGRAPE ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2876
Mailing Address - Country:US
Mailing Address - Phone:541-846-9271
Mailing Address - Fax:
Practice Address - Street 1:369 NE REVERE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4059
Practice Address - Country:US
Practice Address - Phone:541-848-9271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist