Healthcare Provider Details

I. General information

NPI: 1700867272
Provider Name (Legal Business Name): WILLIS MCCOY PRIVOTT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 OPELIKA RD
PHENIX CITY AL
36867-3634
US

IV. Provider business mailing address

1610 OPELIKA RD
PHENIX CITY AL
36867-3634
US

V. Phone/Fax

Practice location:
  • Phone: 334-291-0221
  • Fax: 334-291-1939
Mailing address:
  • Phone: 334-291-0221
  • Fax: 334-291-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number038916
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00017192
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000639416C
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier009986080
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: