Basic Information
| Provider Information | |||||||||
| NPI: | 1841266863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLETT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 INDIGO DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315256865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122612669 | ||||||||
| FaxNumber: | 9122610561 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 MANCHESTER EXPY | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319046878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065964100 | ||||||||
| FaxNumber: | 7065964112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 047174 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 220031645 | 01 | GA | RAILROAD MEDICARE | OTHER | 00837955B | 05 | GA | MEDICAID |