Provider Demographics
NPI:1487857983
Name:WILLIS, JASON S (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:WILLIS
Suffix:
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 1:3213 DREXEL DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205
Mailing Address - Country:US
Mailing Address - Phone:214-437-7975
Mailing Address - Fax:
Practice Address - Street 1:4770 REGENT BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2445
Practice Address - Country:US
Practice Address - Phone:972-934-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9146207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology