Provider Demographics
NPI:1164506184
Name:WILLIS, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
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 1:77 WINSOR ST
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-3469
Mailing Address - Country:US
Mailing Address - Phone:413-589-9494
Mailing Address - Fax:
Practice Address - Street 1:77 WINSOR ST
Practice Address - Street 2:SUITE # 104
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-3469
Practice Address - Country:US
Practice Address - Phone:413-589-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50650208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics