Provider Demographics
NPI:1356565220
Name:WILLEY, RONALD R (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:R
Last Name:WILLEY
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 1:6015 BENJAMIN RD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5179
Mailing Address - Country:US
Mailing Address - Phone:813-886-2616
Mailing Address - Fax:813-886-0858
Practice Address - Street 1:1927 COVE LANE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764
Practice Address - Country:US
Practice Address - Phone:727-536-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME9631207ZP0102X
FLME 9631207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D56199Medicare UPIN
52666Medicare ID - Type Unspecified