Provider Demographics
NPI:1558677401
Name:IRVIN H WILLIS MD PA
Entity Type:Organization
Organization Name:IRVIN H WILLIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-534-6050
Mailing Address - Street 1:4302 ALTON RD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2891
Mailing Address - Country:US
Mailing Address - Phone:305-534-6050
Mailing Address - Fax:305-534-7806
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 630
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-534-6050
Practice Address - Fax:305-534-7806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-28
Last Update Date:2010-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12189208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty