Provider Demographics
NPI:1164426672
Name:KILGORE, WILLIAM TOMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TOMMY
Last Name:KILGORE
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:PO BOX 652
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-0652
Mailing Address - Country:US
Mailing Address - Phone:276-228-3355
Mailing Address - Fax:276-228-6665
Practice Address - Street 1:1785 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1437
Practice Address - Country:US
Practice Address - Phone:276-228-3355
Practice Address - Fax:276-228-6665
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010027306Medicaid
VAB07848Medicare UPIN
VA160001571Medicare ID - Type Unspecified
VA010027306Medicaid