Provider Demographics
NPI:1639127590
Name:WILLARD, KIM MARIA (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIA
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:101 COMMERCE PLACE, SUITE 1
Practice Address - Street 2:COMMUNITY MEDICAL CENTER OF BARNESVILLE
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204
Practice Address - Country:US
Practice Address - Phone:770-358-4408
Practice Address - Fax:770-358-0002
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA029123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA620565904AMedicaid