Provider Demographics
NPI:1083602452
Name:WILLARD, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:WILLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2810
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:817-252-5060
Practice Address - Street 1:1300 W TERRELL AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2810
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:817-252-5060
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0940207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110182266OtherRAIL ROAD MEDICARE
TX85K271OtherBLUE CROSS
TX1378788-01Medicaid
TX137878812Medicaid
TX85K271OtherBLUE CROSS
TX83J624Medicare PIN
TX1378788-01Medicaid
TX137878812Medicaid