Provider Demographics
NPI:1932310679
Name:DAVID WILLIS DO PA
Entity Type:Organization
Organization Name:DAVID WILLIS DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-421-3599
Mailing Address - Street 1:919 LEATHER FERN LANE
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754
Mailing Address - Country:US
Mailing Address - Phone:407-421-3599
Mailing Address - Fax:
Practice Address - Street 1:919 LEATHER FERN LANE
Practice Address - Street 2:
Practice Address - City:MIMS
Practice Address - State:FL
Practice Address - Zip Code:32754
Practice Address - Country:US
Practice Address - Phone:407-421-3599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX I.D.