Provider Demographics
NPI:1861537227
Name:BRIAN M WILLARD MD PC
Entity type:Organization
Organization Name:BRIAN M WILLARD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MCKINLEY
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-253-2968
Mailing Address - Street 1:1108 VAN BUREN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2034
Mailing Address - Country:US
Mailing Address - Phone:610-253-2968
Mailing Address - Fax:610-253-2516
Practice Address - Street 1:1108 VAN BUREN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2034
Practice Address - Country:US
Practice Address - Phone:610-253-2968
Practice Address - Fax:610-253-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049155-L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014371230004Medicaid
PAF50885Medicare UPIN
PA731419Medicare ID - Type Unspecified