Provider Demographics
NPI:1902859762
Name:WILLETT, EDWARD DANIEL
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DANIEL
Last Name:WILLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 EAST PRUDHOMME ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570
Mailing Address - Country:US
Mailing Address - Phone:337-942-6883
Mailing Address - Fax:337-942-6883
Practice Address - Street 1:539 EAST PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570
Practice Address - Country:US
Practice Address - Phone:337-942-6883
Practice Address - Fax:337-942-6883
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD0141142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAE12142Medicare UPIN
LA5R675Medicare ID - Type Unspecified