Provider Demographics
NPI:1346286598
Name:WILLIS, WALTER LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEWIS
Last Name:WILLIS
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:PO BOX 5183
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5183
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-703-9260
Practice Address - Fax:601-703-4050
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11440207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113996Medicaid
MS930261953Medicare ID - Type Unspecified
MS00113996Medicaid