Provider Demographics
NPI:1699962175
Name:WILLIAMS, REGINA LEE (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:F
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:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-8039
Mailing Address - Country:US
Mailing Address - Phone:714-526-0590
Mailing Address - Fax:714-680-8902
Practice Address - Street 1:140 E SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1916
Practice Address - Country:US
Practice Address - Phone:714-526-0590
Practice Address - Fax:714-680-8902
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86894261QH0100X
FLME91427261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
X97874Medicare UPIN