Provider Demographics
NPI:1467441642
Name:WILLINGHAM, DAVID BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BARRY
Last Name:WILLINGHAM
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 1:4222 WENDOVER AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5945
Mailing Address - Country:US
Mailing Address - Phone:432-552-5656
Mailing Address - Fax:432-552-0992
Practice Address - Street 1:4222 WENDOVER AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5945
Practice Address - Country:US
Practice Address - Phone:432-552-5656
Practice Address - Fax:432-552-0992
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0947208D00000X
TXH9047207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3983OtherBCBS PROVIDER NUMBER
TXH0947OtherTX LICENSE NUMBER
TXH0947OtherTX LICENSE NUMBER
TX8G9952Medicare ID - Type UnspecifiedMEDICARE