Provider Demographics
NPI:1760456545
Name:FRIDLEY, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:FRIDLEY
Suffix:
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 1:9201 PINECROFT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3889
Mailing Address - Country:US
Mailing Address - Phone:281-863-9554
Mailing Address - Fax:832-246-8925
Practice Address - Street 1:9201 PINECROFT DR STE 200
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3889
Practice Address - Country:US
Practice Address - Phone:281-863-9554
Practice Address - Fax:832-246-8925
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096695403Medicaid
TX8B8661OtherBCBS OF TEXAS
TX096695404Medicaid
TX096695403Medicaid
TX110232025Medicare PIN
TX110231161Medicare PIN
TX8069B8Medicare PIN
TX8B8661OtherBCBS OF TEXAS