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General NPI Number Information
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NPI Number | 1710901970
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Entity Type | Individual
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Provider Name | DAVID RANDALL WILLIS D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 10/12/2011
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Provider Practice Location Address
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Address Line | 203 TALLAPOOSA STREET
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City | WADLEY
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State | AL
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Zip | 36276
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Country | US
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Telephone | 256-395-4757
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Fax | 256-395-6055
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Provider Business Mailing Address
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Address Line | PO BOX 97
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City | GADSDEN
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State | AL
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Zip | 35902-0097
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Country | US
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Telephone | 256-492-0131
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Fax | 256-494-6000
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO288
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License Number State | AL
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