Provider Demographics
NPI:1225062847
Name:WILLIS, SANDRA E (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:E
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 1:4629 WHITNEY AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821
Mailing Address - Country:US
Mailing Address - Phone:916-482-9800
Mailing Address - Fax:916-482-0537
Practice Address - Street 1:4629 WHITNEY AVE
Practice Address - Street 2:STE 2
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821
Practice Address - Country:US
Practice Address - Phone:916-482-9800
Practice Address - Fax:916-482-0537
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51347OtherSTATE LIC
A51974Medicare UPIN
G51347Medicare ID - Type Unspecified