Provider Demographics
NPI:1295739878
Name:MCKIBBIN, WILLIAM BLAKE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAKE
Last Name:MCKIBBIN
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 1:16 IVY RIDGE LN STE 130
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2354
Mailing Address - Country:US
Mailing Address - Phone:540-332-5909
Mailing Address - Fax:540-332-5910
Practice Address - Street 1:16 IVY RIDGE LN STE 130
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2354
Practice Address - Country:US
Practice Address - Phone:540-332-5909
Practice Address - Fax:540-332-5910
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052784208600000X
VA0101240500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA705155309AMedicaid
GAI12261Medicare UPIN
GA02BBGNZMedicare ID - Type Unspecified