Provider Demographics
NPI:1386679967
Name:OLD, WILLIAM L III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:OLD
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:STE 602
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-534-5511
Practice Address - Fax:757-534-5515
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-08-28
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Provider Licenses
StateLicense IDTaxonomies
VA0101035691208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00360212OtherRAILROAD
VA1386679967Medicaid
VA010285216Medicaid
VA015440R53Medicare PIN
VA1386679967Medicaid