Provider Demographics
NPI:1104285287
Name:WILLIAMS, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 RIVER PARKWAY BLVD
Mailing Address - Street 2:#1108
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-1808
Mailing Address - Country:US
Mailing Address - Phone:318-828-1500
Mailing Address - Fax:318-670-6736
Practice Address - Street 1:1535 RIVER PARKWAY BLVD
Practice Address - Street 2:#1108
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-1808
Practice Address - Country:US
Practice Address - Phone:318-828-1500
Practice Address - Fax:318-670-6736
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2380885172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2380885Medicaid