Provider Demographics
NPI:1699934463
Name:GILLIS, LATRICIA TRENA WILLIS (MD)
Entity type:Individual
Prefix:DR
First Name:LATRICIA
Middle Name:TRENA WILLIS
Last Name:GILLIS
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 1:1717 ROTARY DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-5235
Mailing Address - Country:US
Mailing Address - Phone:281-272-6277
Mailing Address - Fax:281-272-6277
Practice Address - Street 1:3701 KIRBY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-3900
Practice Address - Country:US
Practice Address - Phone:713-798-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPIN# TXB114466Medicare PIN