Healthcare Provider Details

I. General information

NPI: 1174509145
Provider Name (Legal Business Name): WILLERT HOWARD LYNN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 TOWNE PARK DR SUITE 400
RINCON GA
31326-5156
US

IV. Provider business mailing address

PO BOX 2055
RINCON GA
31326-2055
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-1220
  • Fax: 912-826-1216
Mailing address:
  • Phone: 912-826-1220
  • Fax: 912-826-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberGA 47979
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: