Provider Demographics
NPI:1972520567
Name:WILLIS, WILLIAM WYATT (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WYATT
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:WYATT
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:126 TRIVETTE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1275
Mailing Address - Country:US
Mailing Address - Phone:606-432-2202
Mailing Address - Fax:606-432-2429
Practice Address - Street 1:126 TRIVETTE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1275
Practice Address - Country:US
Practice Address - Phone:606-432-2202
Practice Address - Fax:606-432-2429
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02719207Q00000X
WV1592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6403711200Medicaid
KY6403711200Medicaid