Basic Information
| Provider Information | |||||||||
| NPI: | 1851333850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035938441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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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 | F2120 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 139811722 | 05 | TX | MEDICAID | 8CU714 | 01 | TX | BCBS | OTHER | 0042EJ | 01 | TX | BCBS | OTHER | 080126648 | 01 | TX | RAIL ROAD | OTHER | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | 8M5091 | 01 | TX | BCBS | OTHER | TIN PLUS 044 | 01 | TX | TRICARE WINNSBORO LOCATION | OTHER | 75-2616977 | 01 | TX | RAIL ROAD | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | TIN PLUS 015 | 01 | TX | TRICARE TYLER LOCATION | OTHER | 139811714 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 139811724 | 05 | TX | MEDICAID | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 139811723 | 05 | TX | MEDICAID | TIN PLUS 005 | 01 | TX | TRICARE | OTHER | 139811721 | 05 | TX | MEDICAID |