Provider Demographics
NPI:1235261371
Name:WILLIS, DAVID CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
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 1:725 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6321
Mailing Address - Country:US
Mailing Address - Phone:352-732-5211
Mailing Address - Fax:352-732-7145
Practice Address - Street 1:725 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6321
Practice Address - Country:US
Practice Address - Phone:352-732-5211
Practice Address - Fax:352-732-7145
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004839500Medicaid
FL51789OtherBLUECROSS NUMBER
FL004839500Medicaid
FL51789OtherBLUECROSS NUMBER