Provider Demographics
NPI:1508098567
Name:WILLIS, DEMETRIUS JERMAINE (MBA, MS, RD, LD, CPT)
Entity Type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:JERMAINE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MBA, MS, RD, LD, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6422 MERLIN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4661
Mailing Address - Country:US
Mailing Address - Phone:121-048-5841
Mailing Address - Fax:
Practice Address - Street 1:225 E SONTERRA BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3992
Practice Address - Country:US
Practice Address - Phone:210-477-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81138133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered