Healthcare Provider Details

I. General information

NPI: 1386662419
Provider Name (Legal Business Name): WILLIAM RUSSELL GILES JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W MAIN ST
GUN BARREL CITY TX
75156-5297
US

IV. Provider business mailing address

PO BOX 9477
TYLER TX
75711-9477
US

V. Phone/Fax

Practice location:
  • Phone: 903-713-1582
  • Fax: 903-713-1579
Mailing address:
  • Phone: 903-713-1582
  • Fax: 903-713-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM0730
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: