Provider Demographics
NPI:1154376259
Name:WILLIS, CARL ROGASTON (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:ROGASTON
Last Name:WILLIS
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 1:2004 HAYES ST
Mailing Address - Street 2:SUITE 720
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2646
Mailing Address - Country:US
Mailing Address - Phone:615-284-2310
Mailing Address - Fax:615-284-2385
Practice Address - Street 1:2004 HAYES ST
Practice Address - Street 2:SUITE 720
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2646
Practice Address - Country:US
Practice Address - Phone:615-284-2310
Practice Address - Fax:615-284-2385
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN037952207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4090607OtherBCBS OF TN IND PROVIDER #
TN3894844Medicaid
TNI07721Medicare UPIN
TN4090607OtherBCBS OF TN IND PROVIDER #