Provider Demographics
NPI:1740230366
Name:WILLIAMS, ROGER TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:TODD
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-773-2600
Mailing Address - Fax:270-361-5101
Practice Address - Street 1:400 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127-9546
Practice Address - Country:US
Practice Address - Phone:270-773-2600
Practice Address - Fax:270-361-5101
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37488207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64058233Medicaid
KY64058233Medicaid
KY64058233Medicaid
KY0780701Medicare PIN
KY000000299382OtherANTHEM BC/BS
KYP00102087OtherRR MEDICARE