Provider Demographics
NPI:1780676171
Name:WILLIS, IRVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 ALTON RD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2891
Mailing Address - Country:US
Mailing Address - Phone:305-534-6050
Mailing Address - Fax:
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 630
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-534-6050
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12189208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery