Provider Demographics
NPI:1780032706
Name:WILLIS, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHERIDAN SQ STE 102
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7398
Mailing Address - Country:US
Mailing Address - Phone:423-722-5200
Mailing Address - Fax:
Practice Address - Street 1:1 SHERIDAN SQ STE 102
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7398
Practice Address - Country:US
Practice Address - Phone:423-722-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPMOOOOOOO883213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery