Provider Demographics
NPI:1053372920
Name:WILLOCK, ROLAND OSWALD (MD)
Entity type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:OSWALD
Last Name:WILLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9120 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1622
Mailing Address - Country:US
Mailing Address - Phone:414-251-3500
Mailing Address - Fax:414-251-3504
Practice Address - Street 1:9120 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1622
Practice Address - Country:US
Practice Address - Phone:414-251-3500
Practice Address - Fax:414-251-3504
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23094207Q00000X
WI21591-875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1053372920Medicaid