Provider Demographics
NPI:1528062015
Name:WILLIS, AMOS J (MD)
Entity type:Individual
Prefix:DR
First Name:AMOS
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-0328
Mailing Address - Country:US
Mailing Address - Phone:252-489-5829
Mailing Address - Fax:252-376-1163
Practice Address - Street 1:112 WEST WOODHILL DRIVE
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-2795
Practice Address - Country:US
Practice Address - Phone:252-261-8778
Practice Address - Fax:252-715-3446
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010249207W00000X
NC2015-00049207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006352278Medicaid
VA18000320Medicare ID - Type UnspecifiedOPTHAMOLOGY
VA006352278Medicaid