Healthcare Provider Details

I. General information

NPI: 1689885550
Provider Name (Legal Business Name): RANDY DAVID WILLIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19015 U.S. HIGHWAY 441
MT. DORA FL
32757
US

IV. Provider business mailing address

11550 UNIVERSITY BLVD
ORLANDO FL
32817-2100
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-6479
  • Fax:
Mailing address:
  • Phone: 407-384-0080
  • Fax: 407-384-0078

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:
Title or Position:
Credential:
Phone: