Healthcare Provider Details

I. General information

NPI: 1023211547
Provider Name (Legal Business Name): DANIEL LEVI WILLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 NE WYATT CT STE 101
BEND OR
97701-7691
US

IV. Provider business mailing address

PO BOX 6048
BEND OR
97708-6048
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-6447
  • Fax:
Mailing address:
  • Phone: 541-382-4900
  • Fax: 541-706-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberP3486
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberTRN10996
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD208021
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: