Provider Demographics
NPI:1992866040
Name:WILLIS, PARK W IV (MD)
Entity Type:Individual
Prefix:DR
First Name:PARK
Middle Name:W
Last Name:WILLIS
Suffix:IV
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 1:143 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2539
Mailing Address - Country:US
Mailing Address - Phone:919-966-4996
Mailing Address - Fax:919-843-5515
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-4996
Practice Address - Fax:919-843-5515
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000-22374207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988137Medicaid
NC110126328OtherRAIL ROAD MEDICARE
NCC27160Medicare UPIN
NC211605Medicare PIN