Provider Demographics
NPI:1922355155
Name:WILLIS, JOHN CHURCHILL III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHURCHILL
Last Name:WILLIS
Suffix:III
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 1:823 WEEDEN ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3724
Mailing Address - Country:US
Mailing Address - Phone:850-678-7167
Mailing Address - Fax:
Practice Address - Street 1:823 WEEDEN ISLAND DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3724
Practice Address - Country:US
Practice Address - Phone:850-678-7167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine