Healthcare Provider Details

I. General information

NPI: 1477646271
Provider Name (Legal Business Name): WILLIAM NISIMBLAT MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E THIRD ST
ALICE TX
78332-4705
US

IV. Provider business mailing address

PO BOX 289
ALICE TX
78333-4705
US

V. Phone/Fax

Practice location:
  • Phone: 361-664-5291
  • Fax: 361-668-1630
Mailing address:
  • Phone: 361-664-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM NISIMBLAT
Title or Position: OWNER
Credential: MD
Phone: 361-664-5291