Provider Demographics
NPI:1710188248
Name:WILLIS, MARY ALISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALISSA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5500
Mailing Address - Fax:601-984-5503
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:U10
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-8600
Practice Address - Fax:216-445-7013
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL141729Medicaid