Provider Demographics
NPI:1841269248
Name:WILLIAMS, WALTER LEROY (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:LEROY
Last Name:WILLIAMS
Suffix:
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 1:1433 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2714
Mailing Address - Country:US
Mailing Address - Phone:509-758-5141
Mailing Address - Fax:509-758-5299
Practice Address - Street 1:1433 5TH ST.
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2714
Practice Address - Country:US
Practice Address - Phone:509-758-5141
Practice Address - Fax:509-758-5299
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041565207N00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID72157OtherBLUE CROSS OF IDAHO
ID000010139009OtherREGENCE BLUE SHIELD PROV.
WAMD00041565OtherWASHINGTON LICENSE
WAP00007739OtherRAILROAD MEDICARE #
WA1117878OtherWASHINGTON MEDICAID #
ID806377300Medicaid
WA030734610OtherPREMERA BLUE CROSS #
WABW6762834OtherDEA#
ID806377300Medicaid
WAG8806497Medicare PIN