Provider Demographics
NPI:1154322915
Name:WILLIS, JAMES L (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
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 1:1741 DAVID WALKER DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5745
Mailing Address - Country:US
Mailing Address - Phone:352-742-8836
Mailing Address - Fax:352-742-8829
Practice Address - Street 1:1741 DAVID WALKER DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5745
Practice Address - Country:US
Practice Address - Phone:352-742-8836
Practice Address - Fax:352-742-8829
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8915207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268324500Medicaid
FL268324500Medicaid
FL82315ZMedicare PIN