Healthcare Provider Details

I. General information

NPI: 1013978378
Provider Name (Legal Business Name): DALE MICHAEL WILLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD SUITE 931
PORTLAND OR
97225-6636
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-6050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD22738
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: