Provider Demographics
NPI:1235335019
Name:WILLIAMSON, OWEN WINSTON (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:WINSTON
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 LANTERN LN
Mailing Address - Street 2:P.O. BOX 383
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1612
Mailing Address - Country:US
Mailing Address - Phone:215-739-2057
Mailing Address - Fax:215-643-6558
Practice Address - Street 1:121 E LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1011
Practice Address - Country:US
Practice Address - Phone:215-739-2057
Practice Address - Fax:215-643-6558
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021602E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007741300003Medicaid
PAB34487Medicare UPIN
PAWI53817Medicare ID - Type Unspecified