Provider Demographics
NPI:1215958012
Name:WILLIS, JOHN JEFFERY (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JEFFERY
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 1:29 NW 1ST LN
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-8105
Mailing Address - Country:US
Mailing Address - Phone:417-681-5100
Mailing Address - Fax:417-681-5510
Practice Address - Street 1:29 NW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-8105
Practice Address - Country:US
Practice Address - Phone:417-681-5100
Practice Address - Fax:417-681-5510
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006005527207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500410001Medicare PIN