Healthcare Provider Details

I. General information

NPI: 1356565220
Provider Name (Legal Business Name): RONALD R WILLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1927 COVE LANE
CLEARWATER FL
33764
US

IV. Provider business mailing address

6015 BENJAMIN RD SUITE 315
TAMPA FL
33634-5179
US

V. Phone/Fax

Practice location:
  • Phone: 727-536-0687
  • Fax:
Mailing address:
  • Phone: 813-886-2616
  • Fax: 813-886-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME9631
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberME 9631
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: