Basic Information
Provider Information | |||||||||
NPI: | 1699946376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIS | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | LAMAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2050 S BLOSSER RD | ||||||||
Address2: |   | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934587310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053618028 | ||||||||
FaxNumber: | 8053618097 | ||||||||
Practice Location | |||||||||
Address1: | 325 POSADA LN | ||||||||
Address2: | A-C | ||||||||
City: | TEMPLETON | ||||||||
State: | CA | ||||||||
PostalCode: | 934654003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055426700 | ||||||||
FaxNumber: | 8055490465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2008 | ||||||||
LastUpdateDate: | 06/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A102873 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | W1508A | 01 | CA | CHCCC, TEMPLETON NPI# 1275550295 GROUP PTAN# | OTHER | FHC70936F | 05 | CA |   | MEDICAID | W1508 | 01 | CA | CHCCC, NIPOMO MEDICAL CENTER NPI# 1841217866 GROUP PTAN | OTHER | W1508E | 01 | CA | SAN LUIS OBISPO- PTAN GROUP# NPI# 1275550295 | OTHER |