Provider Demographics
NPI:1447201157
Name:WITHAM, WILLIAM R (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:WITHAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1325 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2158
Mailing Address - Country:US
Mailing Address - Phone:817-332-9957
Mailing Address - Fax:817-336-3130
Practice Address - Street 1:1325 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2158
Practice Address - Country:US
Practice Address - Phone:817-332-9957
Practice Address - Fax:817-336-3130
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-08-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL82312086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176760002Medicaid
1D7580OtherCTC - BCBS
TX176760001Medicaid
TX176760001Medicaid
TX176760002Medicaid