Provider Demographics
NPI:1730421124
Name:WILLIS, ERIC WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WILLIAM
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KENNY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2779
Mailing Address - Country:US
Mailing Address - Phone:614-457-8180
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3908
Practice Address - Country:US
Practice Address - Phone:614-566-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.129767207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0264391Medicaid