Provider Demographics
NPI:1477040038
Name:WILLIS, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
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 1072
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78294-1072
Mailing Address - Country:US
Mailing Address - Phone:210-614-3355
Mailing Address - Fax:
Practice Address - Street 1:7810 LOUIS PASTEUR DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3409
Practice Address - Country:US
Practice Address - Phone:210-358-3555
Practice Address - Fax:210-702-4239
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT7083207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology