Healthcare Provider Details

I. General information

NPI: 1811921471
Provider Name (Legal Business Name): JOSHUA MICHAEL WILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 PROFESSIONAL PKWY STE 2080
DOUGLASVILLE GA
30134
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 678-715-5080
  • Fax: 770-942-6420
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number66373
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: