Provider Demographics
NPI:1548253172
Name:WILLIS, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:130 N STREET EXT
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3825
Mailing Address - Country:US
Mailing Address - Phone:508-775-8282
Mailing Address - Fax:508-771-1496
Practice Address - Street 1:130 N STREET EXT
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3825
Practice Address - Country:US
Practice Address - Phone:508-775-8282
Practice Address - Fax:508-771-1496
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160529207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773983Medicaid
2431064OtherAETNA
160529OtherTUFTS
5061233001OtherCIGNA
J21143OtherBCBS
0900676OtherUNITED HEALTH
MA2065118Medicaid
68934OtherPILGRIM
MA9773983Medicaid
5061233001OtherCIGNA
J21143OtherBCBS