Provider Demographics
NPI:1861686834
Name:WILLIAMS, DAVID RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RUSSELL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:856 J CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1318
Practice Address - Country:US
Practice Address - Phone:757-594-4006
Practice Address - Fax:757-594-2195
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1899207Q00000X
ARE5432207Q00000X
VA0102202214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861686834Medicaid
VA020859Q12Medicare PIN
VA1861686834Medicaid