Healthcare Provider Details

I. General information

NPI: 1417990045
Provider Name (Legal Business Name): PHILIP D WILLIAMS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 G ST
SPRINGFIELD OR
97477-4113
US

IV. Provider business mailing address

PO BOX 163
SPRINGFIELD OR
97477-0024
US

V. Phone/Fax

Practice location:
  • Phone: 541-735-9420
  • Fax: 541-747-9870
Mailing address:
  • Phone: 541-735-9420
  • Fax: 541-747-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23771
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number047277
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC55255
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number165948
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: