=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205874534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES B WILLIAMS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 06/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 FRANCISCAN DR
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-776-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2714 BROADMOOR DR
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | K4296
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------