Provider Demographics
NPI:1740235480
Name:WILLIS, DARRELL E (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:E
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:909 ESCUELA AVE
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-4616
Mailing Address - Country:US
Mailing Address - Phone:850-376-6042
Mailing Address - Fax:575-461-7101
Practice Address - Street 1:402 E MIEL DE LUNA AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3828
Practice Address - Country:US
Practice Address - Phone:575-461-7100
Practice Address - Fax:575-461-7101
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256613300Medicaid
FL256613300Medicaid
FLG89728Medicare UPIN