Provider Demographics
NPI:1457556268
Name:WILLIS, BRANDY C (MD)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:C
Last Name:WILLIS
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 12427
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-2427
Mailing Address - Country:US
Mailing Address - Phone:850-297-0114
Mailing Address - Fax:850-297-2020
Practice Address - Street 1:2646 CENTENNIAL PL STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0573
Practice Address - Country:US
Practice Address - Phone:850-702-0300
Practice Address - Fax:850-325-6015
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002105700Medicaid
FLDH653YMedicare PIN