Provider Demographics
NPI:1073507182
Name:WILLIS, ROBERT L (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S CARTER ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64835-1451
Mailing Address - Country:US
Mailing Address - Phone:417-673-3843
Mailing Address - Fax:417-673-1160
Practice Address - Street 1:201 S CARTER ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:MO
Practice Address - Zip Code:64835-1451
Practice Address - Country:US
Practice Address - Phone:417-673-3843
Practice Address - Fax:417-673-1160
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2010-03-05
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
MO10148204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000006295Medicare ID - Type UnspecifiedMF