Provider Demographics
NPI:1376570101
Name:WILLINGHAM, IRENE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:RAE
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4809 COLE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3578
Mailing Address - Country:US
Mailing Address - Phone:214-526-8600
Mailing Address - Fax:214-443-3897
Practice Address - Street 1:4809 COLE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3578
Practice Address - Country:US
Practice Address - Phone:214-526-8600
Practice Address - Fax:214-443-3897
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0463204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine