Provider Demographics
NPI:1851428056
Name:WILLIS, TOM VANN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:VANN
Last Name:WILLIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TOM
Other - Middle Name:VANN
Other - Last Name:WILLIS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:114 MEWS CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5153
Mailing Address - Country:US
Mailing Address - Phone:912-638-3091
Mailing Address - Fax:
Practice Address - Street 1:F L T C 1131 CHAPEL CROSSING RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31524-0001
Practice Address - Country:US
Practice Address - Phone:912-280-5307
Practice Address - Fax:912-267-3196
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10695208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD42027Medicare UPIN