Provider Demographics
NPI:1023009214
Name:WILLYARD, KENT E (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:E
Last Name:WILLYARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8777
Mailing Address - Fax:757-232-8866
Practice Address - Street 1:12695 MCMANUS BLVD
Practice Address - Street 2:BLDG 6, SUITE A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4435
Practice Address - Country:US
Practice Address - Phone:757-969-1755
Practice Address - Fax:757-969-1722
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-01-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101102606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5611679Medicaid
080166573OtherRR/MEDICARE
VA5611679Medicaid
VA080007682Medicare ID - Type Unspecified