Provider Demographics
NPI:1982929741
Name:WILLIS, JOHN HARTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HARTER
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 1:110 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1522
Mailing Address - Country:US
Mailing Address - Phone:336-768-3361
Mailing Address - Fax:336-659-2446
Practice Address - Street 1:110 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-768-3361
Practice Address - Fax:336-659-2446
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088365A207Y00000X
NC2015-00476207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGOtherBCBSNC
PENDINGOtherUNITED HEALTHCARE
NCPENDINGMedicaid
NCPENDINGMedicaid