Basic Information
| Provider Information | |||||||||
| NPI: | 1063432912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLETT | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1717 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272161717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365382390 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | MEBANE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273027639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195632500 | ||||||||
| FaxNumber: | 9195633535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 95-00476 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8987638 | 05 | NC | MEDICAID |