Provider Demographics
NPI:1811921471
Name:WILLIS, JOSHUA MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6001 PROFESSIONAL PKWY STE 2080
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:678-715-5080
Practice Address - Fax:770-942-6420
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66373207RI0011X
TN47184207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I060554Medicare PIN
LA4J453Medicare PIN
TN1525083Medicaid