Provider Demographics
NPI:1295862431
Name:CHARLES E. WILLIS II, M.D., P.A.
Entity Type:Organization
Organization Name:CHARLES E. WILLIS II, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:214-623-0550
Mailing Address - Street 1:PO BOX 1347
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-1347
Mailing Address - Country:US
Mailing Address - Phone:972-991-9950
Mailing Address - Fax:
Practice Address - Street 1:5201 S WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-1622
Practice Address - Country:US
Practice Address - Phone:214-623-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0365207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R03POtherBCBS
TX162314201Medicaid
TX162314201Medicaid
TX00539VMedicare PIN