Provider Demographics
NPI:1386636454
Name:WILLERSON, WILLIAM DARRELL JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DARRELL
Last Name:WILLERSON
Suffix:JR
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 1:303 E QUINCY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1918
Mailing Address - Country:US
Mailing Address - Phone:210-271-7648
Mailing Address - Fax:
Practice Address - Street 1:303 E QUINCY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1918
Practice Address - Country:US
Practice Address - Phone:210-271-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4360207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122723302Medicaid
TX8F1462Medicare UPIN
TX122723302Medicaid