Provider Demographics
NPI:1942404066
Name:WILLIAMS, VAN WAGNER III (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:WAGNER
Last Name:WILLIAMS
Suffix:III
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16492 MLC LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23146-1857
Mailing Address - Country:US
Mailing Address - Phone:804-620-3365
Mailing Address - Fax:804-620-3178
Practice Address - Street 1:16492 MLC LN
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:VA
Practice Address - Zip Code:23146-1857
Practice Address - Country:US
Practice Address - Phone:804-620-3365
Practice Address - Fax:804-620-3178
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044104207Q00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101044104OtherSTATE LICENSE
VABW2186787OtherDEA NUMBER