Provider Demographics
NPI:1710989678
Name:WILLIAMSON, TERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:A
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 DENNY AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5301
Mailing Address - Country:US
Mailing Address - Phone:228-762-3466
Mailing Address - Fax:228-762-6349
Practice Address - Street 1:2819 DENNY AVE.
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5320
Practice Address - Country:US
Practice Address - Phone:228-762-3466
Practice Address - Fax:228-762-6349
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5440159OtherAETNA ID#
MS00116831Medicaid
MS5440159OtherAETNA ID#
MS00116831Medicaid