Provider Demographics
NPI:1356385991
Name:WILLIS, JEFF R (MD)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 W BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1960
Mailing Address - Country:US
Mailing Address - Phone:406-541-6844
Mailing Address - Fax:406-541-6843
Practice Address - Street 1:1930 W BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1960
Practice Address - Country:US
Practice Address - Phone:406-541-6844
Practice Address - Fax:406-541-6843
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT56022207RG0100X
VA0101059226207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15750OtherOPTIMA
VA327082OtherANTHEM
VA100012482OtherMEDICARE RR
VA1659563799OtherGROUP NPI
VA5426240OtherAETNA
NC8905530Medicaid
VA5825041Medicaid
VA100012482OtherMEDICARE RR
NC8905530Medicaid