Provider Demographics
NPI:1023173051
Name:WILLS, MARKETA M (MD)
Entity type:Individual
Prefix:
First Name:MARKETA
Middle Name:M
Last Name:WILLS
Suffix:
Gender:F
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-3318
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:813-974-4325
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1294602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105267800Medicaid
FLZZF9WOtherBLUE CROSS BLUE SHIELD
OH2705997Medicaid
FLL4530OtherMEDICARE