Provider Demographics
NPI:1164480109
Name:BROHAWN, WILLIAM ENSOR III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ENSOR
Last Name:BROHAWN
Suffix:III
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 1:3018 PLANTATION CIR W
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9717
Mailing Address - Country:US
Mailing Address - Phone:662-401-5123
Mailing Address - Fax:
Practice Address - Street 1:3018 PLANTATION CIR W
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9717
Practice Address - Country:US
Practice Address - Phone:662-401-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16756207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME00122484Medicaid
ME00122484Medicaid
MS110002090Medicare PIN