Provider Demographics
NPI:1912111097
Name:WILLIS, ERICK J (MD)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:J
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:PO BOX 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:2828 FIRST AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702
Practice Address - Country:US
Practice Address - Phone:304-399-7565
Practice Address - Fax:304-399-7568
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV99999208000000X
WV23279208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1073527OtherBRICKSTREET
WV3810012988Medicaid
OH2909820Medicaid
WV6570317OtherCIGNA
KY7100066820Medicaid
WV878669OtherCARELINK
OH000000245860Medicaid
WV9865182OtherAETNA
WV4245232Medicare UPIN
OH000000245860Medicaid