Provider Demographics
NPI:1689781619
Name:WILLISTON, PAUL M (OC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:WILLISTON
Suffix:
Gender:M
Credentials:OC
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Mailing Address - Street 1:12199 HIGHWAY 49
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3167
Mailing Address - Country:US
Mailing Address - Phone:228-832-1832
Mailing Address - Fax:228-832-5115
Practice Address - Street 1:12199 HIGHWAY 49
Practice Address - Street 2:SUITE 100
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3167
Practice Address - Country:US
Practice Address - Phone:228-832-1832
Practice Address - Fax:228-832-5115
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist