Basic Information
| Provider Information | |||||||||
| NPI: | 1205843489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | DAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1115 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173515 | ||||||||
| FaxNumber: | 4345724549 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173832 | ||||||||
| FaxNumber: | 4345173649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0102201639 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00301678 | 01 | VA | RR MCARE | OTHER | 462324 | 01 | VA | ANTHEM | OTHER |