Provider Demographics
NPI:1184087959
Name:WILLIS, CHAD (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:WILLIS
Suffix:
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:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1100
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:825 2ND AVE STE C2
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1791
Practice Address - Country:US
Practice Address - Phone:270-780-2780
Practice Address - Fax:270-780-2755
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42665207X00000X
KY56988207X00000X, 207XX0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program