Provider Demographics
NPI:1114959376
Name:WILLIS, PAUL D (LDO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-3027
Mailing Address - Country:US
Mailing Address - Phone:478-781-2818
Mailing Address - Fax:478-746-9865
Practice Address - Street 1:3131 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3027
Practice Address - Country:US
Practice Address - Phone:478-781-2818
Practice Address - Fax:478-746-9865
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001314156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician