Provider Demographics
NPI:1639100340
Name:WILLIS, JEFFREY TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TODD
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 1:1003 HOLLAND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2180
Mailing Address - Country:US
Mailing Address - Phone:601-656-0010
Mailing Address - Fax:601-656-0313
Practice Address - Street 1:1003 HOLLAND AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2180
Practice Address - Country:US
Practice Address - Phone:601-656-0010
Practice Address - Fax:601-656-0313
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12556208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114279Medicaid
MS0114279Medicaid