Basic Information
| Provider Information | |||||||||
| NPI: | 1336143676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W UNDERWOOD ST | ||||||||
| Address2: | STE A | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074223790 | ||||||||
| FaxNumber: | 4074254358 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W UNDERWOOD ST | ||||||||
| Address2: | STE A | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074223790 | ||||||||
| FaxNumber: | 4074254358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | ME43182 | FL | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 057703100 | 05 | FL | MEDICAID |