Provider Demographics
NPI:1144216714
Name:WILLIS, WILLIAM S (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
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:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:850-475-3700
Mailing Address - Fax:
Practice Address - Street 1:4601 SPANISH TRL
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5039
Practice Address - Country:US
Practice Address - Phone:850-969-2001
Practice Address - Fax:850-433-8940
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD32826Medicare UPIN
FL17623YMedicare ID - Type Unspecified