Provider Demographics
NPI:1932219649
Name:WILLIS, ALPHONSO (MD)
Entity Type:Individual
Prefix:
First Name:ALPHONSO
Middle Name:
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:301 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7233
Practice Address - Country:US
Practice Address - Phone:601-288-8282
Practice Address - Fax:601-288-8290
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15624207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS830003891OtherRAILROAD MEDICARE
MS64050757294OtherAMERICAN ADMIN GROUP
MS00118538Medicaid
MS830000072Medicare PIN
MS830003891OtherRAILROAD MEDICARE