Healthcare Provider Details

I. General information

NPI: 1932310679
Provider Name (Legal Business Name): DAVID WILLIS DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 LEATHER FERN LANE
MIMS FL
32754
US

IV. Provider business mailing address

919 LEATHER FERN LANE
MIMS FL
32754
US

V. Phone/Fax

Practice location:
  • Phone: 407-421-3599
  • Fax:
Mailing address:
  • Phone: 407-421-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9622
License Number StateFL

VIII. Authorized Official

Name: DAVID WILLIS
Title or Position: OWNER
Credential: D.O.
Phone: 407-421-3599