Provider Demographics
NPI:1912987975
Name:KATIBAH, WILLIAM G III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:KATIBAH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:304 BILLINGS PL
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-8506
Mailing Address - Country:US
Mailing Address - Phone:704-517-2130
Mailing Address - Fax:704-626-2656
Practice Address - Street 1:10320 MALLARD CREEK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9756
Practice Address - Country:US
Practice Address - Phone:704-517-2130
Practice Address - Fax:877-539-3581
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC31155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947745Medicaid
NCNC5687AMedicare PIN
NC8947745Medicaid
NC212356GMedicare PIN