Healthcare Provider Details

I. General information

NPI: 1154322915
Provider Name (Legal Business Name): JAMES L. WILLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 DAVID WALKER DR
TAVARES FL
32778-5745
US

IV. Provider business mailing address

1741 DAVID WALKER DR
TAVARES FL
32778-5745
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-8836
  • Fax: 352-742-8829
Mailing address:
  • Phone: 352-742-8836
  • Fax: 352-742-8829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8915
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS8915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: