Provider Demographics
NPI:1649399254
Name:WILLIS, GARY GLEN (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:GLEN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 FULLER WISER RD
Mailing Address - Street 2:21206
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039
Mailing Address - Country:US
Mailing Address - Phone:817-685-2544
Mailing Address - Fax:817-557-9721
Practice Address - Street 1:3851 S COOPER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015
Practice Address - Country:US
Practice Address - Phone:817-468-7500
Practice Address - Fax:817-557-9721
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
917804OtherEYEMED
917804OtherEYEMED
T40718Medicare UPIN