Healthcare Provider Details

I. General information

NPI: 1427062926
Provider Name (Legal Business Name): SHIRLEY JEAN WILLIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ELIZABETH ST
OAK HILL WV
25901-2342
US

IV. Provider business mailing address

1001 ELIZABETH ST
OAK HILL WV
25901-2342
US

V. Phone/Fax

Practice location:
  • Phone: 304-465-0447
  • Fax: 304-465-1966
Mailing address:
  • Phone: 304-465-0447
  • Fax: 304-465-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number708OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: