Healthcare Provider Details

I. General information

NPI: 1346347242
Provider Name (Legal Business Name): ROGER D. WILLIAMS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE ZABLOCKI VA MEDICAL CENTER
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

5000 W NATIONAL AVE ZABLOCKI VA MEDICAL CENTER
MILWAUKEE WI
53295-0001
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 414-384-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number983P
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3042
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: