Provider Demographics
NPI:1144454802
Name:COLE, WILLIAM ROBERT (IDMT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
Last Name:COLE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42430 56TH ST W
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536-4450
Mailing Address - Country:US
Mailing Address - Phone:661-839-5673
Mailing Address - Fax:
Practice Address - Street 1:412 MDG EDWARDS AFB CA
Practice Address - Street 2:
Practice Address - City:EDWARDS AFB
Practice Address - State:CA
Practice Address - Zip Code:93524-0001
Practice Address - Country:US
Practice Address - Phone:661-277-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians