Provider Demographics
NPI:1982764551
Name:FANNIN, WILLIAM T (MD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:T
Last Name:FANNIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 WATERGAP RD
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1721
Mailing Address - Country:US
Mailing Address - Phone:606-432-4183
Mailing Address - Fax:
Practice Address - Street 1:9 FLORA STREET
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-432-4183
Practice Address - Fax:606-432-4270
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23326207QA0401X, 207RA0401X
KYKY23326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64233265Medicaid
KY090670Medicare ID - Type Unspecified
KY3313675Medicare PIN
KY64233265Medicaid