Provider Demographics
NPI:1376641316
Name:WILLIS, DIANNA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:MARIE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 EAST TAFT
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6033
Mailing Address - Country:US
Mailing Address - Phone:918-224-8425
Mailing Address - Fax:918-224-8426
Practice Address - Street 1:1305 EAST TAFT
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6033
Practice Address - Country:US
Practice Address - Phone:918-224-8425
Practice Address - Fax:918-224-8426
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100111330DMedicaid
OK339187YLVOMedicare PIN
OK100111330DMedicaid