Provider Demographics
NPI:1053569145
Name:WILLIS, RANDALL MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:MATTHEW
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 1:5508 KINGSTON PIKE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5048
Mailing Address - Country:US
Mailing Address - Phone:865-584-6464
Mailing Address - Fax:
Practice Address - Street 1:207 BRECHIN LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2165
Practice Address - Country:US
Practice Address - Phone:865-406-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN143802083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine