Provider Demographics
NPI:1174729255
Name:WILLIAMS WAYNE, LAURA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:WILLIAMS WAYNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8765 AERO DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-541-0181
Mailing Address - Fax:
Practice Address - Street 1:2790 TRUXTUN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6135
Practice Address - Country:US
Practice Address - Phone:619-610-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60690012207R00000X
CA120225207R00000X
CAA120225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000269324OtherHMSA BILLING NUMBER
HI599780-02Medicaid
HIH102966Medicare PIN