Healthcare Provider Details

I. General information

NPI: 1295175057
Provider Name (Legal Business Name): DEVIN R WILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16555 MANCHESTER RD STE 100
WILDWOOD MO
63040
US

IV. Provider business mailing address

16555 MANCHESTER RD STE 100
WILDWOOD MO
63040-1220
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-0646
  • Fax: 636-458-5008
Mailing address:
  • Phone: 636-458-0646
  • Fax: 636-458-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2016023372
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2016023372
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: