Provider Demographics
NPI:1356347637
Name:WILLIS, SELWYN (DPM)
Entity type:Individual
Prefix:
First Name:SELWYN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPM
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 2202
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2202
Mailing Address - Country:US
Mailing Address - Phone:903-753-3316
Mailing Address - Fax:903-753-3316
Practice Address - Street 1:609 E WHALEY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6526
Practice Address - Country:US
Practice Address - Phone:903-753-3316
Practice Address - Fax:903-753-4344
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018656101Medicaid
TX00DC84Medicare PIN
TX018656101Medicaid