Healthcare Provider Details

I. General information

NPI: 1639092133
Provider Name (Legal Business Name): SOUTHERN OREGON DIRECT PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 STATE ST STE 110
MEDFORD OR
97504-8688
US

IV. Provider business mailing address

3132 STATE ST STE 110
MEDFORD OR
97504-8688
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-4989
  • Fax: 541-293-9812
Mailing address:
  • Phone: 541-500-4989
  • Fax: 541-293-9812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMITY WILLIAMSON
Title or Position: CEO
Credential:
Phone: 541-500-4989