Individual
DR. EMMETT C WILLIS IV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
601 W 2ND ST, BLOOMINGTON, IN 47403-2317
(812) 353-6821
Mailing address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
(336) 716-3202
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
01057781A
IN
207P00000X
Emergency Medicine Physician
Primary
2007-00783
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01057781A
IN LICENSE
IN
01
—
01057781B
CSR
IN
05
—
200446520
—
IN
01
—
2007-00783
NC LICENSE
NC
Enumeration date
09/01/2006
Last updated
03/07/2023
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