Provider Demographics
NPI:1427113588
Name:WILLIS, MELINDA (MD)
Entity type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 FACTORY OUTLET DR
Mailing Address - Street 2:STE 12
Mailing Address - City:ARCADIA
Mailing Address - State:LA
Mailing Address - Zip Code:71001-3057
Mailing Address - Country:US
Mailing Address - Phone:318-263-4701
Mailing Address - Fax:318-263-4704
Practice Address - Street 1:600 FACTORY OUTLET DRIVE
Practice Address - Street 2:STE 12
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-3057
Practice Address - Country:US
Practice Address - Phone:318-263-4701
Practice Address - Fax:318-263-4704
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1909921Medicaid
LA1909921Medicaid
860005Medicare ID - Type Unspecified