MEDICARE: LARRY GRANT 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	207RR0500X	Rheumatology Physician	10557	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	730714291-016	OTHER	OK	BCBS OF OKLAHOMA

General Provider Information

NPI Number	:	1952309155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY GRANT WILLIS MD

Provider Business Mailing Address
First Line	:	PO BOX 268981
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-8981
Country	:	US
Telephone Number	:	405-230-9000
Fax Number	:	405-230-9375

Provider Business Practice Location Address
First Line	:	1110 N LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-2612
Country	:	US
Telephone Number	:	405-230-9000
Fax Number	:	405-230-9443

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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