Provider Demographics
NPI:1205891207
Name:WILLIS, JOHN M (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 MATLOCK RD STE 130
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4295
Mailing Address - Country:US
Mailing Address - Phone:682-242-8990
Mailing Address - Fax:682-242-8996
Practice Address - Street 1:252 MATLOCK RD STE 130
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4295
Practice Address - Country:US
Practice Address - Phone:682-242-8990
Practice Address - Fax:682-242-8996
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129827510Medicaid
TX8X9688OtherBLUE CROSS
TX129827510Medicaid
TX8X9688OtherBLUE CROSS