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General NPI Number Information
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NPI Number | 1265847016
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Entity Type | Individual
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Provider Name | ZACHARY WILLIS D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/30/2014
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Last Update Date | 06/30/2014
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Provider Practice Location Address
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Address Line | 2345 DOUGHERTY FERRY RD
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City | SAINT LOUIS
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State | MO
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Zip | 63122-3313
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Country | US
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Telephone | 314-966-9100
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Fax |
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Provider Business Mailing Address
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Address Line | 243 VALLEY VIEW RIDGE DR
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City | VALLEY PARK
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State | MO
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Zip | 63088-1338
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Country | US
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Telephone | 239-851-5888
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 2014017955
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License Number State | MO
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