Provider Demographics
NPI:1508854290
Name:WILLIS, NORMAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:ROBERT
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 1:6489 SW BORLAND RD
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9798
Mailing Address - Country:US
Mailing Address - Phone:503-692-4843
Mailing Address - Fax:503-692-6543
Practice Address - Street 1:504 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2439
Practice Address - Country:US
Practice Address - Phone:208-799-5600
Practice Address - Fax:208-799-5755
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD094272085R0203X, 2085R0001X
IDM-141142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00WCHDSAMedicare PIN
ORC90990Medicare UPIN