Provider Demographics
NPI:1770535247
Name:WILLIS, EARNESTINE (MD)
Entity type:Individual
Prefix:DR
First Name:EARNESTINE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5433 W FOND DU LAC AVE
Mailing Address - Street 2:MIDTOWN PEDIATRICS
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1382
Mailing Address - Country:US
Mailing Address - Phone:414-277-8900
Mailing Address - Fax:414-277-8939
Practice Address - Street 1:5433 W FOND DU LAC AVE
Practice Address - Street 2:MIDTOWN PEDIATRICS
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1382
Practice Address - Country:US
Practice Address - Phone:414-277-8900
Practice Address - Fax:414-277-8939
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI36231208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000197OOtherHUMANA
WI1770535247Medicaid
WI1770535247Medicaid
002000197OOtherHUMANA