Provider Demographics
NPI:1487488219
Name:WILLIS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N MICKEY MANTLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:OK
Mailing Address - Zip Code:74339-1110
Mailing Address - Country:US
Mailing Address - Phone:918-675-4100
Mailing Address - Fax:918-675-4615
Practice Address - Street 1:130 W STEVE OWENS BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-7629
Practice Address - Country:US
Practice Address - Phone:918-542-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist