Provider Demographics
NPI:1851579643
Name:I E WILLIS JR DPM PC
Entity type:Organization
Organization Name:I E WILLIS JR DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:DR
Authorized Official - First Name:SELWYN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-753-3316
Mailing Address - Street 1:PO BOX 2202
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2202
Mailing Address - Country:US
Mailing Address - Phone:903-753-3316
Mailing Address - Fax:
Practice Address - Street 1:609 E WHALEY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6526
Practice Address - Country:US
Practice Address - Phone:903-753-3316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0280213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0350780001Medicare NSC