Provider Demographics
NPI:1316902281
Name:FANNIN, OLIVER WILLIAM III (MD)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:WILLIAM
Last Name:FANNIN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 CEDAR PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-4517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 E 15TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1930
Practice Address - Country:US
Practice Address - Phone:512-324-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7324207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138853023Medicaid
TX138853024OtherCIDC
TX8Y0017OtherBCBS OF TX
TX8G1375Medicare PIN
TXP00319799Medicare PIN
TXF92616Medicare UPIN
TX138853023Medicaid
TX8F1928Medicare PIN
TX8J8726Medicare PIN
TX8901M4Medicare PIN
TX8F0119Medicare PIN
TX8J5436Medicare PIN
TX8D3972Medicare PIN
TX8C6465Medicare PIN
TX8B8895Medicare PIN
TX138853024OtherCIDC