Provider Demographics
NPI:1598746554
Name:WILLETT, DWIGHT H (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:H
Last Name:WILLETT
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 1:820 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2120
Mailing Address - Country:US
Mailing Address - Phone:865-376-3406
Mailing Address - Fax:865-376-9091
Practice Address - Street 1:820 W RACE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2120
Practice Address - Country:US
Practice Address - Phone:865-376-3406
Practice Address - Fax:865-376-9091
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD010763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3173428Medicaid
TNQ021922Medicaid
TN17855OtherBLUE CROSS
B03594Medicare UPIN