Provider Demographics
NPI:1770928145
Name:WILLINGHAM, DAVID RYAN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RYAN
Last Name:WILLINGHAM
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 1:1402 W AVENUE H
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-5342
Mailing Address - Country:US
Mailing Address - Phone:254-771-8414
Mailing Address - Fax:
Practice Address - Street 1:1402 W AVENUE H
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5342
Practice Address - Country:US
Practice Address - Phone:254-771-8401
Practice Address - Fax:254-771-8493
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10047348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10047348OtherTEXAS MEDICAL BOARD