Provider Demographics
NPI:1245477587
Name:WILLIAMS, DAVEEDA GAILES (PROVIDER)
Entity type:Individual
Prefix:MRS
First Name:DAVEEDA
Middle Name:GAILES
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 VERBENA ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2154
Mailing Address - Country:US
Mailing Address - Phone:903-276-4210
Mailing Address - Fax:430-200-0403
Practice Address - Street 1:4618 VERBENA ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2154
Practice Address - Country:US
Practice Address - Phone:903-276-4210
Practice Address - Fax:430-200-0403
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA10017951251K00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251K00000XAgenciesPublic Health or Welfare