Provider Demographics
NPI:1831194216
Name:WILLIS, RUDOLPH E (MD)
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:E
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 1:355 CRAWFORD ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2819
Mailing Address - Country:US
Mailing Address - Phone:757-396-6333
Mailing Address - Fax:757-396-6367
Practice Address - Street 1:355 CRAWFORD ST
Practice Address - Street 2:STE 300
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2819
Practice Address - Country:US
Practice Address - Phone:757-396-6333
Practice Address - Fax:757-396-6367
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233411207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89067J2OtherNC MEDICAID
VAP00013926OtherRAILROAD MEDICARE
VA437204OtherANTHEM BCBS
VA59557OtherOPTIMA HEALTH PLAN
VA374935OtherMAMSI/MDIPA
VA001085C11Medicare ID - Type UnspecifiedMEDICARE
VA59557OtherOPTIMA HEALTH PLAN