Provider Demographics
NPI:1093712705
Name:WILLIS, DENNIS EARL (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:EARL
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 1:8637 FREDERICKSBURG RD
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1283
Mailing Address - Country:US
Mailing Address - Phone:210-617-4708
Mailing Address - Fax:210-617-4075
Practice Address - Street 1:2455 NE LOOP 410
Practice Address - Street 2:STE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5649
Practice Address - Country:US
Practice Address - Phone:210-599-6000
Practice Address - Fax:210-599-7519
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK7950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8D4767Medicare ID - Type Unspecified
G97509Medicare UPIN