Provider Demographics
NPI:1699946376
Name:WILLIS, DANIEL LAMAR (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LAMAR
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 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:325 POSADA LN
Practice Address - Street 2:A-C
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4003
Practice Address - Country:US
Practice Address - Phone:805-542-6700
Practice Address - Fax:805-549-0465
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1508AOtherCHCCC, TEMPLETON NPI# 1275550295 GROUP PTAN#
CAFHC70936FMedicaid
CAW1508OtherCHCCC, NIPOMO MEDICAL CENTER NPI# 1841217866 GROUP PTAN
CAW1508EOtherSAN LUIS OBISPO- PTAN GROUP# NPI# 1275550295
CAW1508OtherCHCCC, NIPOMO MEDICAL CENTER NPI# 1841217866 GROUP PTAN