Provider Demographics
NPI:1194768382
Name:WILLIAMS, GORDON FRANK (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:FRANK
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 W KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5010
Practice Address - Country:US
Practice Address - Phone:336-623-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39977207P00000X
VA0101241909207P00000X
TNMD39977207R00000X, 208000000X, 2080P0204X, 207R00000X
NC2021-00786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4153169OtherBLUE CROSS
TN3334468Medicaid
TN4108063OtherBLUE CROSS
NC5910413Medicaid
TNP00254453OtherRRGA
TN3334467Medicaid
VA1194768382Medicaid
VAVV0858CMedicare PIN
TN3334467Medicaid
TN103I116129Medicare PIN
TN3334468Medicare PIN