Provider Demographics
NPI:1710901970
Name:WILLIS, DAVID RANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDALL
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902-0097
Mailing Address - Country:US
Mailing Address - Phone:256-492-0131
Mailing Address - Fax:256-494-6000
Practice Address - Street 1:203 TALLAPOOSA STREET
Practice Address - Street 2:
Practice Address - City:WADLEY
Practice Address - State:AL
Practice Address - Zip Code:36276
Practice Address - Country:US
Practice Address - Phone:256-395-4757
Practice Address - Fax:256-395-6055
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110498Medicaid
AL009995350Medicaid
AL102I930643Medicare PIN
AL110498Medicaid