Provider Demographics
NPI:1023116415
Name:MCILVAINE, WILLIAM B (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:MCILVAINE
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 1:4800 ALBERTA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2709
Mailing Address - Country:US
Mailing Address - Phone:915-215-5625
Mailing Address - Fax:915-545-6984
Practice Address - Street 1:4800 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2709
Practice Address - Country:US
Practice Address - Phone:915-215-5625
Practice Address - Fax:915-545-6984
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43753207L00000X
TXN8124207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G437530 F91OtherCAL OPTIMA
CA00G437530Medicaid
CA00G437530 F91OtherCAL OPTIMA
CAWG43753AMedicare ID - Type Unspecified