Basic Information
| Provider Information | |||||||||
| NPI: | 1528166287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBSTER | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | WALLACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | A40097 | CA | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207P00000X | A40097 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Y00000X | MD27455 | OR | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | CB3544 | 01 | OR | TRAV RR MEDICARE GROUP PTAN | OTHER | 274244 | 05 | OR | MEDICAID | 1407812365 | 01 | OR | MEDICARE GROUP NPI NUMBER | OTHER | R0000WFBTV | 01 | OR | MEDICARE GROUP PIN NUMBER | OTHER | P00628020 | 01 | OR | TRAV RR MEDICARE PTAN | OTHER |