Provider Demographics
NPI:1902090434
Name:WILLIAM A. FAWCETT, IV, MD
Entity Type:Organization
Organization Name:WILLIAM A. FAWCETT, IV, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:409-892-7090
Mailing Address - Street 1:2965 HARRISON ST STE 315
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1150
Mailing Address - Country:US
Mailing Address - Phone:409-892-7090
Mailing Address - Fax:409-892-4324
Practice Address - Street 1:2965 HARRISON ST STE 315
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1150
Practice Address - Country:US
Practice Address - Phone:409-892-7090
Practice Address - Fax:409-892-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0998207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147396901Medicaid
00092NMedicare PIN