Provider Demographics
NPI:1902870611
Name:WILLIS, DONALD CLINTON (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CLINTON
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7272
Mailing Address - Fax:423-439-7235
Practice Address - Street 1:325 N STATE OF FRANKLIN RD FL 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-439-7272
Practice Address - Fax:423-439-7235
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD57056207VM0101X
FLME30920207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039811000Medicaid
FL039811000Medicaid
FLC23596Medicare UPIN