MEDICARE: JONATHAN WILLIS M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program	BP10053880	TX
2	207Q00000X	Family Medicine Physician	R0157	TX

General Provider Information

NPI Number	:	1437538162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN WILLIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 848476
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-8476
Country	:	US
Telephone Number	:	254-202-4655
Fax Number	:	254-202-4697

Provider Business Practice Location Address
First Line	:	851 N LOOP 340
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76705-2592
Country	:	US
Telephone Number	:	254-202-7500
Fax Number	:	254-202-7599

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

Provider Enumeration Date	:	05/27/2015
Last Update Date	:	09/01/2020

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