Provider Demographics
NPI:1003880667
Name:WILLIS, WAYNE S (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:S
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 1:3111 PEGGY BOND DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5018
Mailing Address - Country:US
Mailing Address - Phone:850-438-9755
Mailing Address - Fax:850-438-0699
Practice Address - Street 1:3111 PEGGY BOND DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5018
Practice Address - Country:US
Practice Address - Phone:850-438-9755
Practice Address - Fax:850-438-0699
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17364OtherBLUE CROSS BLUE SHIELD
AL591-83896OtherBLUE CROSS BLUE SHIELD
FL069681100Medicaid
FL17364XMedicare PIN
AL591-83896OtherBLUE CROSS BLUE SHIELD