Provider Demographics
NPI:1275561623
Name:WILLIS, STEVEN MATHIAS (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MATHIAS
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 BUFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4466
Mailing Address - Country:US
Mailing Address - Phone:850-878-3999
Mailing Address - Fax:850-942-4587
Practice Address - Street 1:1911 BUFORD BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4466
Practice Address - Country:US
Practice Address - Phone:850-878-3999
Practice Address - Fax:850-942-4587
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003581111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88595Medicare ID - Type Unspecified
FLT55898Medicare UPIN