Provider Demographics
NPI:1497792089
Name:WILLIS, DAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:A
Last Name:WILLIS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1650 W ROSEDALE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7426
Mailing Address - Country:US
Mailing Address - Phone:817-877-5381
Mailing Address - Fax:817-877-3992
Practice Address - Street 1:1000 9TH AVE
Practice Address - Street 2:STE. B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3906
Practice Address - Country:US
Practice Address - Phone:817-877-5381
Practice Address - Fax:817-877-3992
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2018-06-16
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Provider Licenses
StateLicense IDTaxonomies
TXE2944207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113953703Medicaid
TX113953701Medicaid
TX113953703Medicaid
TXC23594Medicare UPIN