Provider Demographics
NPI:1235131665
Name:WILLIS, FRED S (MD)
Entity Type:Individual
Prefix:
First Name:FRED
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 32600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-2600
Mailing Address - Country:US
Mailing Address - Phone:318-212-4877
Mailing Address - Fax:318-212-4192
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:318-212-4500
Practice Address - Fax:318-212-4143
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020188207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1390780Medicaid
LA1390780Medicaid
E25179Medicare UPIN