Provider Demographics
NPI:1568430841
Name:WILLIAMS, RYAN GENTRY (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:GENTRY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MT CLEMENT PARK
Practice Address - Street 2:SUITE C
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5098
Practice Address - Country:US
Practice Address - Phone:804-443-6063
Practice Address - Fax:804-443-6005
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102201877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015464R53Medicare PIN
VA1568430841Medicaid
VAP00432155Medicare PIN
VAI49138Medicare UPIN