Provider Demographics
NPI:1740377787
Name:FUSSELL, WILLIE MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:MICHAEL
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2800 OLD DAWSON ROAD
Mailing Address - Street 2:SUITE 2, BOX 245
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1599
Mailing Address - Country:US
Mailing Address - Phone:229-405-2470
Mailing Address - Fax:229-405-2473
Practice Address - Street 1:3200 GILLIONVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-2815
Practice Address - Country:US
Practice Address - Phone:229-405-2470
Practice Address - Fax:229-405-2473
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57620208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017790060001Medicaid
GA202I255775Medicare PIN
PA0000108210Medicare PIN