Provider Demographics
NPI:1053486704
Name:WILLIS, KENNETH DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DEAN
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:PO BOX 18084
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8084
Mailing Address - Country:US
Mailing Address - Phone:256-882-2003
Mailing Address - Fax:256-705-4630
Practice Address - Street 1:3007 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5393
Practice Address - Country:US
Practice Address - Phone:256-882-2003
Practice Address - Fax:256-705-4630
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12320207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529908240Medicaid
AL00098275Medicare PIN
AL529908240Medicaid