Provider Demographics
NPI:1427062926
Name:WILLIS, SHIRLEY JEAN (OD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:JEAN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-2342
Mailing Address - Country:US
Mailing Address - Phone:304-465-0447
Mailing Address - Fax:304-465-1966
Practice Address - Street 1:1001 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-2342
Practice Address - Country:US
Practice Address - Phone:304-465-0447
Practice Address - Fax:304-465-1966
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV708OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3105016000Medicaid
WV0332290001Medicare PIN
WV3105016000Medicaid
WV410048497Medicare PIN
WV1891965737Medicare PIN
WVT32561Medicare UPIN