Provider Demographics
NPI:1225308554
Name:WILLIS, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
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 1:56 RIVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4523
Mailing Address - Country:US
Mailing Address - Phone:985-892-2509
Mailing Address - Fax:
Practice Address - Street 1:56 RIVERDALE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4523
Practice Address - Country:US
Practice Address - Phone:985-892-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0088552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology