Provider Demographics
NPI:1326137514
Name:WILLIS, MARK C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:WILLIS
Suffix:JR
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 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:ORTHOPAEDIC SURGERY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0510
Practice Address - Country:US
Practice Address - Phone:804-828-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053689207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010093074 54158118Medicaid
VA005326M90 C03690Medicare ID - Type Unspecified
005326M90Medicare PIN
VA010093074 54158118Medicaid