MEDICARE: MRS. LAKISHA JEANETTE BURTON WILLIS MBA, M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	4301188560	MI
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1902288962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAKISHA JEANETTE BURTON WILLIS MBA, M.D.

Provider Business Mailing Address
First Line	:	4188 OLD DOMINION DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2659
Country	:	US
Telephone Number	:	313-701-8811
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 E CANFIELD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-1928
Country	:	US
Telephone Number	:	313-577-1102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	02/23/2016

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