MEDICARE: JUSTIN ALLAN WILLIS IDC

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	1710I1002X	Independent Duty Corpsman	W4204214450	FL

General Provider Information

NPI Number	:	1619420536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN ALLAN WILLIS IDC

Provider Business Mailing Address
First Line	:	8353 IRIS AVE
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33777-3643
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8353 IRIS AVE
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33777-3643
Country	:	US
Telephone Number	:	727-288-4516
Fax Number	:

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

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/27/2016

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Directions to “ JUSTIN ALLAN WILLIS IDC” Practice Location

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