Provider Demographics
NPI:1699743534
Name:WILLIAMSON, MARK L (IDC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
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Mailing Address - Street 1:COMDESRON ONE 3325 SENN ROAD
Mailing Address - Street 2:BUILDING 55 SECOND FLOOR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136
Mailing Address - Country:US
Mailing Address - Phone:619-556-5002
Mailing Address - Fax:619-556-5003
Practice Address - Street 1:3325 SENN ROAD
Practice Address - Street 2:COMDESRON ONE BUILDING 55 SECOND FLOOR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136
Practice Address - Country:US
Practice Address - Phone:619-556-5002
Practice Address - Fax:619-556-5003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman