Provider Demographics
NPI:1053582999
Name:WILLIAMSBURG MEDICAL CARE PC
Entity type:Organization
Organization Name:WILLIAMSBURG MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-302-2126
Mailing Address - Street 1:155 POWERS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4973
Mailing Address - Country:US
Mailing Address - Phone:718-302-2126
Mailing Address - Fax:718-392-2128
Practice Address - Street 1:155 POWERS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4973
Practice Address - Country:US
Practice Address - Phone:718-302-2126
Practice Address - Fax:718-392-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215832207R00000X
NY225308207R00000X
NY023838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty