Provider Demographics
NPI:1952309155
Name:WILLIS, LARRY GRANT (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:GRANT
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 268981
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8981
Mailing Address - Country:US
Mailing Address - Phone:405-230-9000
Mailing Address - Fax:405-230-9375
Practice Address - Street 1:1110 N LEE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2612
Practice Address - Country:US
Practice Address - Phone:405-230-9000
Practice Address - Fax:405-230-9443
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10557207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730714291-016OtherBCBS OF OKLAHOMA
OK730714291-016OtherBCBS OF OKLAHOMA