Provider Demographics
NPI:1194833475
Name:WILLIS, MARSHALL F (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:F
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PREMIER FAMILY MEDICAL
Mailing Address - Street 2:275 W 200 N
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4047
Mailing Address - Country:US
Mailing Address - Phone:801-756-3511
Mailing Address - Fax:801-756-1705
Practice Address - Street 1:830 N 2000 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4047
Practice Address - Country:US
Practice Address - Phone:801-756-3511
Practice Address - Fax:801-756-1705
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1650701205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107006253101OtherSELECT HEALTH
UT870293873W11OtherEMIA
UTQMXAF02074OtherALTIUS
UT06409Medicaid
UT0456OtherDESERET MUTUAL BENEFIT AS
UT3213OtherPEHP
UT87029387384062B006OtherTRICARE
UT87029387384062B006OtherTRICARE
UT080027689Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT870293873W11OtherEMIA