Provider Demographics
NPI:1356761191
Name:WILLIS, SIMON MATT (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:MATT
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 1:114 CANAL ST STE 503
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4261
Mailing Address - Country:US
Mailing Address - Phone:912-450-6300
Mailing Address - Fax:912-450-6303
Practice Address - Street 1:114 CANAL ST STE 503
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4261
Practice Address - Country:US
Practice Address - Phone:912-450-6300
Practice Address - Fax:912-450-6303
Is Sole Proprietor?:No
Enumeration Date:2014-04-20
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC833772081P2900X
GA846802081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine