MEDICARE: DR. JEFFREY TODD 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	208D00000X	General Practice Physician	12556	MS

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	:	1639100340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY TODD WILLIS MD

Provider Business Mailing Address
First Line	:	1003 HOLLAND AVE STE 104
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2180
Country	:	US
Telephone Number	:	601-656-0010
Fax Number	:	601-656-0313

Provider Business Practice Location Address
First Line	:	1003 HOLLAND AVE STE 104
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2180
Country	:	US
Telephone Number	:	601-656-0010
Fax Number	:	601-656-0313

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	11/16/2020

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