Provider Demographics
NPI:1255369450
Name:WILLIAMS, FREDDIE ALVIN JR (MD)
Entity type:Individual
Prefix:
First Name:FREDDIE
Middle Name:ALVIN
Last Name:WILLIAMS
Suffix:JR
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:PO BOX 1229
Mailing Address - Street 2:
Mailing Address - City:SO PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-1229
Mailing Address - Country:US
Mailing Address - Phone:213-842-4354
Mailing Address - Fax:323-296-8673
Practice Address - Street 1:4060 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LA
Practice Address - State:CA
Practice Address - Zip Code:90023-3526
Practice Address - Country:US
Practice Address - Phone:323-268-5514
Practice Address - Fax:323-296-8613
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53688207L00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A536880OtherBLUE SHIELD
CA00A536880Medicaid
CAWA53688AMedicare ID - Type Unspecified
CAA53688Medicare Oscar/Certification
CA00A536880Medicaid