Provider Demographics
NPI:1295763928
Name:DEFEE, WILLIAM JACKSON III (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACKSON
Last Name:DEFEE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1390
Mailing Address - Street 2:
Mailing Address - City:TIOGA
Mailing Address - State:LA
Mailing Address - Zip Code:71477-1390
Mailing Address - Country:US
Mailing Address - Phone:318-640-7847
Mailing Address - Fax:318-640-7108
Practice Address - Street 1:5507 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-3533
Practice Address - Country:US
Practice Address - Phone:318-640-7847
Practice Address - Fax:318-640-7108
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA011645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1118907Medicaid
LA1118907Medicaid
LAB62945Medicare UPIN