Provider Demographics
NPI:1174510937
Name:WILLIS, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:2501 OREGON PIKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4890
Mailing Address - Country:US
Mailing Address - Phone:717-293-3223
Mailing Address - Fax:717-390-2455
Practice Address - Street 1:99 HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6423
Practice Address - Country:US
Practice Address - Phone:732-557-8051
Practice Address - Fax:732-557-2064
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA079321002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCF1652OtherRAILROAD MEDICARE
NJCF1652OtherRAILROAD MEDICARE
NJ158432Medicare PIN
NJ094974AFUMedicare PIN