Provider Demographics
NPI:1255392064
Name:WILLIS, EMANUEL (DPM)
Entity type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 HARDEE CV
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1893
Mailing Address - Country:US
Mailing Address - Phone:803-469-9255
Mailing Address - Fax:803-469-9253
Practice Address - Street 1:2630A HARDEE CV
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1893
Practice Address - Country:US
Practice Address - Phone:803-469-9255
Practice Address - Fax:803-469-9253
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9925Medicaid
SCPD0886Medicaid
SCU31518Medicare UPIN
SCPD0886Medicaid