Provider Demographics
NPI:1679649396
Name:WILLIS, STUART KENDALL III (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:KENDALL
Last Name:WILLIS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:STUART KENDALL
Other - Last Name:WILLIS
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:HCR 85 BOX 8133
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-6365
Mailing Address - Fax:208-267-2202
Practice Address - Street 1:6640 KANIKSU ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-4850
Practice Address - Fax:208-267-2202
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM9300OtherID B OF M
IDM9300OtherID B OF M
IDM9300OtherID B OF M
H10124Medicare UPIN