Basic Information
| Provider Information | |||||||||
| NPI: | 1497825160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | ALEXIA | ||||||||
| MiddleName: | SMITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804211127 | ||||||||
| FaxNumber: | 5804366674 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804211127 | ||||||||
| FaxNumber: | 5804366674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 27510 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 19356 | 01 | MS | MEDICAL LICENSE | OTHER | BM9828015 | 01 | MS | DEA | OTHER | 000097196 | 01 | BCBSMT | OTHER |