Healthcare Provider Details

I. General information

NPI: 1912125345
Provider Name (Legal Business Name): MATTHEW DEAN WILLIS MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST POB 122
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST POTTER 3
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4515
  • Fax: 401-444-7018
Mailing address:
  • Phone: 401-444-4318
  • Fax: 401-444-6573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD13403
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD13403
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD13403
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: