Provider Demographics
NPI:1376683904
Name:WILLIAMS, DARREN SHAUN (PT)
Entity Type:Individual
Prefix:MR
First Name:DARREN
Middle Name:SHAUN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6717 MURRAY PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3911
Mailing Address - Country:US
Mailing Address - Phone:858-692-5835
Mailing Address - Fax:619-825-7500
Practice Address - Street 1:6717 MURRAY PARK DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3911
Practice Address - Country:US
Practice Address - Phone:858-692-5835
Practice Address - Fax:619-825-7500
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0203280Medicaid
CAG0001798OtherMUTUAL OF OMAHA
CA148929OtherNATIONWIDE
CAG0001798OtherMUTUAL OF OMAHA
CAQ05218Medicare UPIN