Provider Demographics
NPI:1275812505
Name:SOUTH, WILLIAM ROBERT
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:SOUTH
Suffix:
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:PS 451
Mailing Address - Street 2:BOX 340
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-2800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC451
Practice Address - Street 2:BOX340
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09834-2800
Practice Address - Country:US
Practice Address - Phone:318-439-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman