Provider Demographics
NPI:1174844864
Name:CHAD D. WILLIS, D.O., P.C.
Entity Type:Organization
Organization Name:CHAD D. WILLIS, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-531-0022
Mailing Address - Street 1:5402 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9521
Mailing Address - Country:US
Mailing Address - Phone:580-531-0022
Mailing Address - Fax:580-531-0026
Practice Address - Street 1:5402 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9521
Practice Address - Country:US
Practice Address - Phone:580-531-0022
Practice Address - Fax:580-531-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4875207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty