Provider Demographics
NPI:1225015274
Name:WILLYARD, DAVID C (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:WILLYARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2927
Practice Address - Country:US
Practice Address - Phone:260-347-8556
Practice Address - Fax:260-347-8557
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000891A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000111943OtherANTHEM
IN000000570546OtherANTHEM
00001004235 01OtherUNITED HEALTHCARE
IN080130360OtherRAILROAD MEDICARE
IN100263140Medicaid
IN2022OtherPHYSICIANS HEALTH PLAN
IN3937240016OtherMEDICARE DMEPOS
4205599OtherAETNA
IN100263140Medicaid
00001004235 01OtherUNITED HEALTHCARE
IN069990AMedicare PIN