Provider Demographics
NPI:1487139135
Name:WILLSON, DAVID BLAIR
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BLAIR
Last Name:WILLSON
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 1:2223 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-4523
Mailing Address - Country:US
Mailing Address - Phone:806-744-4646
Mailing Address - Fax:806-368-8746
Practice Address - Street 1:3711 20TH ST STE C
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1223
Practice Address - Country:US
Practice Address - Phone:806-744-4645
Practice Address - Fax:806-368-8746
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80717332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment