Provider Demographics
NPI:1821014648
Name:WILLIS, BRIAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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 1:2510 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3119
Mailing Address - Country:US
Mailing Address - Phone:318-716-4850
Mailing Address - Fax:318-716-4954
Practice Address - Street 1:2510 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-716-4850
Practice Address - Fax:318-716-4954
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9030207T00000X
LA016892207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1936936Medicaid
LAE22717Medicare UPIN
LA5R178D924Medicare ID - Type Unspecified