Provider Demographics
NPI:1700979739
Name:NISIMBLAT, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:NISIMBLAT
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:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333
Mailing Address - Country:US
Mailing Address - Phone:361-664-5291
Mailing Address - Fax:361-668-1630
Practice Address - Street 1:305 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4705
Practice Address - Country:US
Practice Address - Phone:361-664-5291
Practice Address - Fax:361-668-1630
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1214496-03OtherTESAS HEALTH STEPS
TX121449601Medicaid
TX121449602Medicaid
TXE77721Medicare UPIN
TX1214496-03OtherTESAS HEALTH STEPS