Healthcare Provider Details

I. General information

NPI: 1982929741
Provider Name (Legal Business Name): JOHN HARTER WILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3361
  • Fax: 336-659-2446
Mailing address:
  • Phone: 336-768-3361
  • Fax: 336-659-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01088365A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2015-00476
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: