Provider Demographics
NPI:1164639175
Name:WILLIS, GARTH J (MD)
Entity Type:Individual
Prefix:
First Name:GARTH
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:300 PLAZA CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-8260
Mailing Address - Country:US
Mailing Address - Phone:570-421-8842
Mailing Address - Fax:
Practice Address - Street 1:300 PLAZA CT
Practice Address - Street 2:SUITE A
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8260
Practice Address - Country:US
Practice Address - Phone:570-421-8842
Practice Address - Fax:570-476-5842
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2013-12-06
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Provider Licenses
StateLicense IDTaxonomies
PAMT186286207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023014720001Medicaid
PA1023014720001Medicaid