Provider Demographics
NPI:1104899962
Name:WILLIS, THOMAS LESTER (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LESTER
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 HEATHER ST
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4854
Mailing Address - Country:US
Mailing Address - Phone:936-637-6522
Mailing Address - Fax:
Practice Address - Street 1:302 HEATHER ST
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-4854
Practice Address - Country:US
Practice Address - Phone:936-637-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133768505Medicaid
TX133768505Medicaid
TX87M521Medicare PIN