Basic Information
| Provider Information | |||||||||
| NPI: | 1144229659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | DEWITT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546886 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 HIGHWAY 365 | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEDERLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776276249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/18/2006 | ||||||||
| NPIReactivationDate: | 03/29/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | C8288 | TX | N | Other Service Providers | Specialist | 207RG0300X | C8288 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | C8288 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 133790915 | 05 | TX | MEDICAID | 8CU673 | 01 | TX | BCBS | OTHER |