Provider Demographics
NPI:1265847016
Name:WILLIS, ZACHARY (DO)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
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 1:243 VALLEY VIEW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1338
Mailing Address - Country:US
Mailing Address - Phone:239-851-5888
Mailing Address - Fax:
Practice Address - Street 1:2345 DOUGHERTY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3313
Practice Address - Country:US
Practice Address - Phone:314-966-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014017955208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery