Provider Demographics
NPI:1194773549
Name:WILLIAMS, LANCE
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3364
Practice Address - Country:US
Practice Address - Phone:806-775-8445
Practice Address - Fax:806-775-8412
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00255872085R0202X
TXU30552085R0202X
NC98015582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807532800Medicaid
OH2674575Medicaid
NC1590190Medicaid
PA0015901900008Medicaid
PAP00378980OtherRXR MEDICARE
PA878110XREMedicare PIN
G28884Medicare UPIN
NC1590190Medicaid
ID807532800Medicaid