Healthcare Provider Details

I. General information

NPI: 1639127590
Provider Name (Legal Business Name): KIM MARIA WILLARD M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 MAIN ST
PALMETTO GA
30268-1138
US

IV. Provider business mailing address

643 MAIN ST
PALMETTO GA
30268-1138
US

V. Phone/Fax

Practice location:
  • Phone: 404-929-8824
  • Fax: 404-929-9769
Mailing address:
  • Phone: 404-929-8824
  • Fax: 404-929-9769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number029123
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: