Provider Demographics
NPI:1689604449
Name:ROBERTS, WILLIS REID JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIS
Middle Name:REID
Last Name:ROBERTS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 N COLUMBIA ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-6448
Mailing Address - Country:US
Mailing Address - Phone:478-453-0662
Mailing Address - Fax:478-452-8067
Practice Address - Street 1:2803 N COLUMBIA ST UNIT D
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-6448
Practice Address - Country:US
Practice Address - Phone:478-453-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00826999BMedicaid
GA52702166OtherBCBS OF GA
GA045116OtherMEDICAL LICENSE
GAG98520Medicare UPIN
GA52702166OtherBCBS OF GA
GA11BDRXPMedicare PIN
GRP4142Medicare PIN