Provider Demographics
NPI:1972783736
Name:ROGER WILLIAMS MD PC
Entity Type:Organization
Organization Name:ROGER WILLIAMS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-532-5838
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0010
Mailing Address - Country:US
Mailing Address - Phone:928-535-6667
Mailing Address - Fax:928-535-5561
Practice Address - Street 1:5448 WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5739
Practice Address - Country:US
Practice Address - Phone:928-532-5838
Practice Address - Fax:928-532-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty