Provider Demographics
NPI:1013957950
Name:CHOCTAW, WILLIAM THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:CHOCTAW
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 1:315 NORTH 3RD AVENUE
Mailing Address - Street 2:SUTIE 200
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-938-1165
Mailing Address - Fax:626-938-1172
Practice Address - Street 1:315 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1915
Practice Address - Country:US
Practice Address - Phone:626-938-1165
Practice Address - Fax:626-938-1172
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG029056208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G290560Medicaid
CAA43944Medicare UPIN
CA00G290560Medicaid