Provider Demographics
NPI:1679678205
Name:WOMACK, WILLIAM BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRIAN
Last Name:WOMACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.0. BOX 9479
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426
Mailing Address - Country:US
Mailing Address - Phone:928-768-9496
Mailing Address - Fax:
Practice Address - Street 1:1611 JOY LN
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8807
Practice Address - Country:US
Practice Address - Phone:928-768-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ518144Medicaid
AZ71873OtherPTAN
AZH18091Medicare UPIN
AZ71873OtherPTAN