Healthcare Provider Details

I. General information

NPI: 1972701837
Provider Name (Legal Business Name): LARRY DEAN WILLIAMSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S CASINO CENTER BLVD
LAS VEGAS NV
89101-6102
US

IV. Provider business mailing address

330 S CASINO CENTER BLVD
LAS VEGAS NV
89101-6102
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5637
  • Fax: 702-366-0576
Mailing address:
  • Phone: 702-671-5637
  • Fax: 702-366-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21286
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8304
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: