Provider Demographics
NPI:1437146156
Name:PEELLE, WILLIS W (MD)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:W
Last Name:PEELLE
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 1:2345 W LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8012
Mailing Address - Country:US
Mailing Address - Phone:765-455-4075
Mailing Address - Fax:765-455-4094
Practice Address - Street 1:2345 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8012
Practice Address - Country:US
Practice Address - Phone:765-455-4075
Practice Address - Fax:765-455-4094
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024373208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200063040Medicaid
000000085569OtherBC
IN363950Medicare ID - Type Unspecified
000000085569OtherBC