Provider Demographics
NPI:1598772006
Name:KILLINGSWORTH, DANIEL WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILLIAM
Last Name:KILLINGSWORTH
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 1:1499 WALTON WAY
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-8403
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2273
Practice Address - Fax:706-721-1158
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56307207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA56307OtherMEDICAL LICENSE NUMBER
GA611384568AMedicaid
AL12092OtherMEDICAL LICENSE NUMBER
SCG56307Medicaid
511I180003Medicare PIN
GA611384568AMedicaid