Healthcare Provider Details

I. General information

NPI: 1457585481
Provider Name (Legal Business Name): WATOTO PEDIATRIC & ADOLESCENT SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 LAKE MANASSAS DRIVE SUITE 209
GAINESVILLE VA
20155-3260
US

IV. Provider business mailing address

7915 LAKE MANASSAS DRIVE SUITE 209
GAINESVILLE VA
20155-3260
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-0679
  • Fax: 571-261-9549
Mailing address:
  • Phone: 571-248-0679
  • Fax: 571-261-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. IRVING C WILLIAMS II
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 571-248-0679