=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710484910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN DUSTIN WILLIS DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2018
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 N VILLAGE AVE STE 211
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-714-3743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100108
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32610-0108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-265-0535
-----------------------------------------------------
Fax | 352-627-4173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | 321467
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | OS20663
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 321467
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------