Provider Demographics
NPI:1528040458
Name:PRIMOS, WILLIAM ANGELO JR (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ANGELO
Last Name:PRIMOS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:108 PROMINENCE CT STE 200
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6340
Practice Address - Country:US
Practice Address - Phone:770-848-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC393362080S0010X
GA423952080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN39665Medicaid
GA813658737AMedicaid
NC8969208Medicaid
GA813658737AMedicaid
GA813658737AMedicaid