Provider Demographics
NPI:1689793481
Name:WILLIAMS, LARRY DOUGLAS
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DOUGLAS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5200
Mailing Address - Country:US
Mailing Address - Phone:310-392-9474
Mailing Address - Fax:
Practice Address - Street 1:2701 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5200
Practice Address - Country:US
Practice Address - Phone:310-392-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17OtherOTHER SERVICE PROVIDER