Provider Demographics
NPI:1053619973
Name:WILLIS, GEORGE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:EDWARD
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 1:12251 SW 69TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5425
Mailing Address - Country:US
Mailing Address - Phone:305-663-1342
Mailing Address - Fax:
Practice Address - Street 1:12251 SW 69TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5425
Practice Address - Country:US
Practice Address - Phone:305-663-1342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 45994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 45994OtherMEDICAL LICENSE
FLME 45994OtherMEDICAL LICENSE