1497700074 NPI number — SALISA K WILLIAMS OD

Table of content: SALISA K WILLIAMS OD (NPI 1497700074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497700074 NPI number — SALISA K WILLIAMS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
SALISA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497700074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEHALIS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98532-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-242-3008
Provider Business Mailing Address Fax Number:
360-807-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 NE 129TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-3252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-694-2544
Provider Business Practice Location Address Fax Number:
360-694-1356
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3116ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OD00004059 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G8883203 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8893963 . This is a "MEDICARE WA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00378195 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8882481 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8925843 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2032092 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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