Provider Demographics
NPI:1750370383
Name:WILLIS, TIFFANY (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1331
Mailing Address - Country:US
Mailing Address - Phone:319-642-5213
Mailing Address - Fax:319-642-3636
Practice Address - Street 1:255 W LUCAS ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1331
Practice Address - Country:US
Practice Address - Phone:319-642-5213
Practice Address - Fax:319-642-3636
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
39640OtherWELLMARK