Provider Demographics
NPI:1578777389
Name:WILLIS, BRADLEY S (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 FAIRVIEW HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-9308
Mailing Address - Country:US
Mailing Address - Phone:304-872-8545
Mailing Address - Fax:304-872-0675
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-872-8545
Practice Address - Fax:304-872-0675
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV23490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine