Provider Demographics
NPI:1033179478
Name:WILLIS, WILLIAM ALLEN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALLEN
Last Name:WILLIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 42005
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-2005
Mailing Address - Country:US
Mailing Address - Phone:910-223-9801
Mailing Address - Fax:910-223-9819
Practice Address - Street 1:2850 VILLAGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3864
Practice Address - Country:US
Practice Address - Phone:910-223-9801
Practice Address - Fax:910-223-9819
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC224492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-88133Medicaid
NCC89005Medicare UPIN
NC202042EMedicare ID - Type Unspecified