Provider Demographics
NPI:1104434042
Name:KILLINGSWORTH, MICHAEL AUSTIN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:AUSTIN
Last Name:KILLINGSWORTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 SUMMITT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5370
Mailing Address - Country:US
Mailing Address - Phone:479-964-2670
Mailing Address - Fax:
Practice Address - Street 1:798 W SERVICE RD
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1727
Practice Address - Country:US
Practice Address - Phone:870-732-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3595152W00000X
AR2820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist