Provider Demographics
NPI:1912157033
Name:WETZEL D. WILLIAMS MD, PC
Entity Type:Organization
Organization Name:WETZEL D. WILLIAMS MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'NAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-327-3617
Mailing Address - Street 1:1509 MOSSEY CUP DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-327-3617
Mailing Address - Fax:
Practice Address - Street 1:608 E COMMANCHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-327-3617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM58-62207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D36041Medicare UPIN
2108113Medicare PIN