Healthcare Provider Details

I. General information

NPI: 1972783736
Provider Name (Legal Business Name): ROGER WILLIAMS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5448 WHITE MOUNTAIN BLVD SUITE 270
LAKESIDE AZ
85929-5739
US

IV. Provider business mailing address

PO BOX 10
OVERGAARD AZ
85933-0010
US

V. Phone/Fax

Practice location:
  • Phone: 928-532-5838
  • Fax: 928-532-6670
Mailing address:
  • Phone: 928-535-6667
  • Fax: 928-535-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22260
License Number StateAZ

VIII. Authorized Official

Name: ROGER T WILLIAMS
Title or Position: PRESIDENT
Credential: MD
Phone: 928-532-5838