Provider Demographics
NPI:1467511501
Name:WILLEY, EDWARD NORBURN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:NORBURN
Last Name:WILLEY
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 1:7869 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2730
Mailing Address - Country:US
Mailing Address - Phone:727-345-2907
Mailing Address - Fax:
Practice Address - Street 1:6727 1ST AVE S
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1339
Practice Address - Country:US
Practice Address - Phone:727-345-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10854207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF04304Medicare UPIN