Healthcare Provider Details

I. General information

NPI: 1649965492
Provider Name (Legal Business Name): SEAN WILLIAMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 06/29/2023
Certification Date: 06/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST # MSAG407Q
TEMPLE TX
76508-0001
US

IV. Provider business mailing address

4803 BELLFALLS CT
TEMPLE TX
76502
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-5437
  • Fax:
Mailing address:
  • Phone: 205-902-2581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number764463
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: