Provider Demographics
NPI:1609860220
Name:WILLIAMS, WINSTON SAMUEL JR (MD)
Entity Type:Individual
Prefix:
First Name:WINSTON
Middle Name:SAMUEL
Last Name:WILLIAMS
Suffix:JR
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 339
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-0339
Mailing Address - Country:US
Mailing Address - Phone:530-926-5613
Mailing Address - Fax:530-926-8798
Practice Address - Street 1:50 ALAMO AVE
Practice Address - Street 2:
Practice Address - City:WEED
Practice Address - State:CA
Practice Address - Zip Code:96094-2352
Practice Address - Country:US
Practice Address - Phone:530-938-3491
Practice Address - Fax:530-938-2662
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010053798OtherRAILROAD MEDICARE
CA00G491250Medicaid
A51271Medicare UPIN
00G491250Medicare PIN