Provider Demographics
NPI:1073561346
Name:WILLIS, ADELAIDE (MD)
Entity Type:Individual
Prefix:DR
First Name:ADELAIDE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W WEST COVINA PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2708
Mailing Address - Country:US
Mailing Address - Phone:626-960-8614
Mailing Address - Fax:626-960-8624
Practice Address - Street 1:1500 W WEST COVINA PKWY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2708
Practice Address - Country:US
Practice Address - Phone:626-960-8614
Practice Address - Fax:626-960-8624
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A441310Medicaid
CADA322ZMedicare PIN
CAF12098Medicare UPIN