MEDICARE: JAMES L. WILLIS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS8915	FL
2	208M00000X	Hospitalist Physician	OS8915	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154322915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES L. WILLIS D.O.

Provider Business Mailing Address
First Line	:	1741 DAVID WALKER DR
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-5745
Country	:	US
Telephone Number	:	352-742-8836
Fax Number	:	352-742-8829

Provider Business Practice Location Address
First Line	:	1741 DAVID WALKER DR
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-5745
Country	:	US
Telephone Number	:	352-742-8836
Fax Number	:	352-742-8829

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	08/22/2016

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