Provider Demographics
NPI:1467979328
Name:WILLIS, BRIANNA (OD)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-6912
Mailing Address - Country:US
Mailing Address - Phone:713-492-5003
Mailing Address - Fax:
Practice Address - Street 1:5854 EASTEX FWY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-4824
Practice Address - Country:US
Practice Address - Phone:409-899-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9268T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1366555229Medicaid