Provider Demographics
NPI:1750373460
Name:WILLIAMS, ROGER MARK (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:MARK
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4388
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4388
Mailing Address - Country:US
Mailing Address - Phone:337-477-6172
Mailing Address - Fax:337-477-1422
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-477-6172
Practice Address - Fax:337-477-1422
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016891207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366901Medicaid
LA76-0216590OtherTRICARE/CHAMPUS
LA1366901Medicaid
LA1366901Medicaid
LAC23530Medicare UPIN