Provider Demographics
NPI:1821014648
Name:WILLIS, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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 1:1002 TEXAS BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5113
Mailing Address - Country:US
Mailing Address - Phone:903-794-4196
Mailing Address - Fax:903-792-7408
Practice Address - Street 1:1002 TEXAS BLVD STE 406
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5113
Practice Address - Country:US
Practice Address - Phone:903-794-4196
Practice Address - Fax:903-792-7408
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016892207T00000X
TXP9030207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1936936Medicaid
LAE22717Medicare UPIN
LA5R178D924Medicare ID - Type Unspecified