Provider Demographics
NPI:1205838463
Name:INGRAM, WILLIAM T (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:INGRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENOLDEN
Mailing Address - State:PA
Mailing Address - Zip Code:19036-1101
Mailing Address - Country:US
Mailing Address - Phone:610-461-6450
Mailing Address - Fax:610-461-1842
Practice Address - Street 1:901 W ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GLENOLDEN
Practice Address - State:PA
Practice Address - Zip Code:19036-1101
Practice Address - Country:US
Practice Address - Phone:610-461-6450
Practice Address - Fax:610-461-1842
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006603L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007049930005Medicaid
PA080085421Medicare PIN
PA568787K9LMedicare PIN
PA568787YDMTMedicare PIN