Provider Demographics
NPI:1518174820
Name:WILLIAM GEORGE KATIBAH III
Entity Type:Organization
Organization Name:WILLIAM GEORGE KATIBAH III
Other - Org Name:MALLARD CREEK FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:KATIBAH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:704-547-9500
Mailing Address - Street 1:10320 MALLARD CREEK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5204
Mailing Address - Country:US
Mailing Address - Phone:704-547-9500
Mailing Address - Fax:704-547-9515
Practice Address - Street 1:10320 MALLARD CREEK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9756
Practice Address - Country:US
Practice Address - Phone:704-547-9500
Practice Address - Fax:704-547-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty