Provider Demographics
NPI:1689646457
Name:PANNELL, WILLIAM P JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
Last Name:PANNELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E 4TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3729
Mailing Address - Country:US
Mailing Address - Phone:229-273-9050
Mailing Address - Fax:229-276-3641
Practice Address - Street 1:416 A 4TH AVE E
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-273-9050
Practice Address - Fax:229-276-3641
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15713208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00119523GMedicaid
GA00119523BMedicaid
GA00119523FMedicaid
GA00119523FMedicaid
02BDGWJMedicare PIN