Provider Demographics
NPI:1689885550
Name:WILLIS, RANDY DAVID (DO)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DAVID
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-2100
Mailing Address - Country:US
Mailing Address - Phone:407-384-0080
Mailing Address - Fax:407-384-0078
Practice Address - Street 1:19015 U.S. HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MT. DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-383-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine