Provider Demographics
NPI:1578655361
Name:POWELL, WILLIE L JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:L
Last Name:POWELL
Suffix:JR
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:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:770-801-2500
Mailing Address - Fax:
Practice Address - Street 1:1825 HIGHWAY 34 E
Practice Address - Street 2:ST. 3000
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1325
Practice Address - Country:US
Practice Address - Phone:770-252-6767
Practice Address - Fax:404-564-5902
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08CBCBRMedicare PIN
GAE81765Medicare UPIN