Provider Demographics
NPI:1740269612
Name:WILLIS, MARK L (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1108 ROSS CLARK CIRCLE
Mailing Address - Street 2:SOUTHEAST PAIN MGMT CENTER
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-793-8196
Mailing Address - Fax:334-699-4757
Practice Address - Street 1:208 HAVEN DR
Practice Address - Street 2:SOUTHEAST PAIN MGMT CENTER
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2909
Practice Address - Country:US
Practice Address - Phone:334-793-8196
Practice Address - Fax:334-699-4757
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00025952207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA622443016AOtherMEDICAID
51521334OtherBCBS OF AL
GA622443016AOtherMEDICAID