Basic Information
| Provider Information | |||||||||
| NPI: | 1598772006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILLINGSWORTH | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068288403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067212273 | ||||||||
| FaxNumber: | 7067211158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 04/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 56307 | GA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 56307 | 01 | GA | MEDICAL LICENSE NUMBER | OTHER | 611384568A | 05 | GA | MEDICAID | 12092 | 01 | AL | MEDICAL LICENSE NUMBER | OTHER | G56307 | 05 | SC | MEDICAID |