Provider Demographics
NPI:1619900537
Name:WILLIS, HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HOWARD
Other - Middle Name:CLARENCE
Other - Last Name:WILLIS
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1005 TALBOTTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8757
Mailing Address - Country:US
Mailing Address - Phone:706-321-3901
Mailing Address - Fax:706-321-3904
Practice Address - Street 1:1005 TALBOTTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8757
Practice Address - Country:US
Practice Address - Phone:706-321-3901
Practice Address - Fax:706-321-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030693302F00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA673454OtherBCBSGA
GA000368893HMedicaid
GA000368893EMedicaid
GA000368893GMedicaid
AL009900840Medicaid
GA673454OtherBCBSGA
GA11BDPMC07Medicare ID - Type UnspecifiedTALBOTTON SITE
GA000368893GMedicaid
GA000368893HMedicaid