Provider Demographics
NPI:1649388364
Name:WILLISTON, SHAILA N (MD)
Entity Type:Individual
Prefix:
First Name:SHAILA
Middle Name:N
Last Name:WILLISTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WELLS ROAD
Mailing Address - Street 2:SHAILA N WILLISTON MD STE 27
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-264-0359
Mailing Address - Fax:
Practice Address - Street 1:1700 WELLS ROAD
Practice Address - Street 2:SHAILA N WILLISTON MD STE 27
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-264-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037983200Medicaid
FL15506Medicare ID - Type Unspecified
FL037983200Medicaid