Provider Demographics
NPI:1700867272
Name:PRIVOTT, WILLIS MCCOY JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:MCCOY
Last Name:PRIVOTT
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 1:1610 OPELIKA RD
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-3634
Mailing Address - Country:US
Mailing Address - Phone:334-291-0221
Mailing Address - Fax:334-291-1939
Practice Address - Street 1:1610 OPELIKA RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3634
Practice Address - Country:US
Practice Address - Phone:334-291-0221
Practice Address - Fax:334-291-1939
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038916208000000X
AL00017192208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000639416CMedicaid
AL009986080Medicaid
AL009986080Medicaid