Healthcare Provider Details

I. General information

NPI: 1710484910
Provider Name (Legal Business Name): SEAN DUSTIN WILLIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N VILLAGE AVE STE 211
ROCKVILLE CENTRE NY
11570-1001
US

IV. Provider business mailing address

PO BOX 100108
GAINESVILLE FL
32610-0108
US

V. Phone/Fax

Practice location:
  • Phone: 516-714-3743
  • Fax:
Mailing address:
  • Phone: 352-265-0535
  • Fax: 352-627-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number321467
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberOS20663
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number321467
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: