Provider Demographics
NPI:1184812729
Name:KING, WILLARD DAVID
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:DAVID
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76374-0266
Mailing Address - Country:US
Mailing Address - Phone:940-564-2982
Mailing Address - Fax:940-564-2932
Practice Address - Street 1:101 EAST MAIN
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:TX
Practice Address - Zip Code:76374
Practice Address - Country:US
Practice Address - Phone:940-564-2982
Practice Address - Fax:940-564-2932
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2008-01-07
Deactivation Date:2007-10-15
Deactivation Code:
Reactivation Date:2008-01-07
Provider Licenses
StateLicense IDTaxonomies
TX041759332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011903401Medicaid
TX011903401Medicaid