Basic Information
| Provider Information | |||||||||
| NPI: | 1023211547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | LEVI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6048 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977086048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824900 | ||||||||
| FaxNumber: | 5417062398 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 NE WYATT CT STE 101 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413826447 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | P3486 | TX | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | TRN10996 | FL | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD208021 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 311365601 | 05 | TX | MEDICAID | 8DQ392 | 01 | TX | BCBS | OTHER |