Provider Demographics
NPI:1942392097
Name:GWILLIAM, SUZANNE JANE (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:JANE
Last Name:GWILLIAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 SW REDWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224
Mailing Address - Country:US
Mailing Address - Phone:503-620-7358
Mailing Address - Fax:503-624-6144
Practice Address - Street 1:6640 SW REDWOOD LANE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-620-7358
Practice Address - Fax:503-624-6144
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR063524Medicaid
F74251Medicare UPIN
08WCHQRJMedicare ID - Type Unspecified