Provider Demographics
NPI:1679622062
Name:WILLETT, DAVID P (MD,PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:WILLETT
Suffix:
Gender:M
Credentials:MD,PA
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 1004
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-1004
Mailing Address - Country:US
Mailing Address - Phone:864-288-4765
Mailing Address - Fax:
Practice Address - Street 1:5-B EAST OWENS LANE
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2635
Practice Address - Country:US
Practice Address - Phone:864-288-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8962Medicare PIN
SCA98404Medicare UPIN