Provider Demographics
NPI:1457345423
Name:WILLIAMS, EDMUND P IV (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:P
Last Name:WILLIAMS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1380 PANTHEON WAY
Mailing Address - Street 2:STE 310
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2288
Mailing Address - Country:US
Mailing Address - Phone:210-404-9696
Mailing Address - Fax:210-404-9466
Practice Address - Street 1:1380 PANTHEON WAY
Practice Address - Street 2:STE 310
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2288
Practice Address - Country:US
Practice Address - Phone:210-404-9696
Practice Address - Fax:210-404-9466
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3912207Q00000X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138419010Medicaid
0003AYMedicare ID - Type Unspecified
TX138419010Medicaid