MEDICARE: CHARLES E WILLIS MD

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	J0365	TX
2	208VP0000X	Pain Medicine Physician	J0365	TX

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
2	00R03P	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1336142983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES E WILLIS MD

Provider Business Mailing Address
First Line	:	PO BOX 1347
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-1347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 YORK DR STE 205
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-2064
Country	:	US
Telephone Number	:	214-623-0550
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	01/27/2026

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Directions to “ CHARLES E WILLIS MD” Practice Location

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