Provider Demographics
NPI:1588190318
Name:WILLIAMS, GARY II (LAC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:WILLIAMS
Suffix:II
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 REFLECTION DR APT 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3182
Mailing Address - Country:US
Mailing Address - Phone:619-794-9078
Mailing Address - Fax:
Practice Address - Street 1:3225 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5701
Practice Address - Country:US
Practice Address - Phone:619-794-9078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17575171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist