Provider Demographics
NPI:1790711141
Name:WILLIE, CLAIRE K (MD)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:K
Last Name:WILLIE
Suffix:
Gender:F
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-0009
Mailing Address - Country:US
Mailing Address - Phone:770-907-4949
Mailing Address - Fax:770-907-4022
Practice Address - Street 1:1324 HIGHWAY 138 SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1404
Practice Address - Country:US
Practice Address - Phone:770-907-4949
Practice Address - Fax:770-907-4022
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00639779Medicaid
GAF59367Medicare UPIN
GA11BDSHVMedicare PIN