Healthcare Provider Details

I. General information

NPI: 1336167600
Provider Name (Legal Business Name): SHAWN RAY WILLIAMS D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 MARBACH RD
SAN ANTONIO TX
78227-1911
US

IV. Provider business mailing address

311 JONES MILL RD
STATESBORO GA
30458-4765
US

V. Phone/Fax

Practice location:
  • Phone: 210-761-3393
  • Fax: 210-761-3397
Mailing address:
  • Phone: 912-764-6236
  • Fax: 912-764-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number066841
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT3902
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: