Provider Demographics
NPI:1528166287
Name:WEBSTER, WILLIAM WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALLACE
Last Name:WEBSTER
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 1:1900 WOODLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4580
Practice Address - Street 1:1900 WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4580
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40097207K00000X, 207P00000X
ORMD27455207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCB3544OtherTRAV RR MEDICARE GROUP PTAN
OR274244Medicaid
OR1407812365OtherMEDICARE GROUP NPI NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORP00628020OtherTRAV RR MEDICARE PTAN
ORP00628020OtherTRAV RR MEDICARE PTAN
ORI60772Medicare UPIN
OR274244Medicaid
ORR137631Medicare PIN