Provider Demographics
NPI:1700830064
Name:WILLIARD, WILLIAM CLARENCE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CLARENCE
Last Name:WILLIARD
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 1:3920 CAPITOL MALL DR SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8700
Mailing Address - Country:US
Mailing Address - Phone:360-754-1029
Mailing Address - Fax:360-754-7885
Practice Address - Street 1:3920 CAPITOL MALL DR SW
Practice Address - Street 2:SUITE 201
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8700
Practice Address - Country:US
Practice Address - Phone:360-754-1029
Practice Address - Fax:360-754-7885
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029497174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB21325OtherPTAN
WA8272346Medicaid
WAGAB21325OtherPTAN