Provider Demographics
NPI:1700882180
Name:WILLIS, WILLIAM JOHN (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
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 1:15 FOX RUN RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1785
Mailing Address - Country:US
Mailing Address - Phone:908-403-2863
Mailing Address - Fax:
Practice Address - Street 1:3130 ROUTE 10
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-3455
Practice Address - Country:US
Practice Address - Phone:973-442-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA57865174400000X
NJ25MA05786500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F46572Medicare UPIN
NJ034859Medicare ID - Type Unspecified