Provider Demographics
NPI:1295091486
Name:CHARLES R WILLIAMS MD PA
Entity type:Organization
Organization Name:CHARLES R WILLIAMS MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-236-3385
Mailing Address - Street 1:804 MEDICAL CIRCLE DR. SUITE H
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605
Mailing Address - Country:US
Mailing Address - Phone:903-236-3385
Mailing Address - Fax:
Practice Address - Street 1:804 MEDICAL CIRCLE
Practice Address - Street 2:SUITE H
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-236-3385
Practice Address - Fax:903-236-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089595501Medicaid
TX089595501Medicaid