Provider Demographics
NPI:1336455443
Name:WILLIAMS, PURVIS QUINTIN (IDC)
Entity type:Individual
Prefix:
First Name:PURVIS
Middle Name:QUINTIN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8352 KRENZ ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:619-556-3294
Mailing Address - Fax:
Practice Address - Street 1:USS INDEPENDENCE LCS 2
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96668-0103
Practice Address - Country:US
Practice Address - Phone:619-556-3294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman