Provider Demographics
NPI:1760488498
Name:IRVINE, WILLIAM DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DAVID
Last Name:IRVINE
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 1:1000 VANN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6061
Mailing Address - Country:US
Mailing Address - Phone:731-668-3161
Mailing Address - Fax:731-668-3162
Practice Address - Street 1:1000 VANN DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6061
Practice Address - Country:US
Practice Address - Phone:731-668-3161
Practice Address - Fax:731-668-3162
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000024247207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4097024OtherBLUE CROSS BLUE SHIELD
TN3325382Medicaid
MS4097024OtherBLUE CROSS BLUE SHIELD
TN3325382Medicaid
TN3370388Medicare PIN
TN3325382Medicare ID - Type Unspecified
TN3075155Medicare PIN