Provider Demographics
NPI:1205843489
Name:WILLIAMS, DAN A JR
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:A
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:
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 1115
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592
Mailing Address - Country:US
Mailing Address - Phone:434-517-3515
Mailing Address - Fax:434-572-4549
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-517-3832
Practice Address - Fax:434-517-3649
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201639207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00301678OtherRR MCARE
VA462324OtherANTHEM
H66574Medicare UPIN
VAP00301678OtherRR MCARE