Provider Demographics
NPI:1497794259
Name:WILLIS, EDWARD R JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:WILLIS
Suffix:JR
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 2697
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-2697
Mailing Address - Country:US
Mailing Address - Phone:228-467-5121
Mailing Address - Fax:
Practice Address - Street 1:100 DRINKWATER RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1614
Practice Address - Country:US
Practice Address - Phone:228-467-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41094207Y00000X
MS10751207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS040000118Medicare ID - Type Unspecified
B64334Medicare UPIN