Provider Demographics
NPI:1619967577
Name:WILLIAMS, VERN R (MD)
Entity Type:Individual
Prefix:
First Name:VERN
Middle Name:R
Last Name:WILLIAMS
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 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:15 N MORRIS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1541
Practice Address - Country:US
Practice Address - Phone:503-230-9875
Practice Address - Fax:503-230-9877
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14502207RA0401X, 207RA0401X
HIMD-17867207RA0401X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2107839Medicaid
OR134254Medicaid
ORC91054Medicare UPIN