Provider Demographics
NPI:1235290487
Name:WILLIS, ROBERT HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HOWARD
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 1:177 E 87TH ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2226
Mailing Address - Country:US
Mailing Address - Phone:212-410-6666
Mailing Address - Fax:
Practice Address - Street 1:177 E 87TH ST
Practice Address - Street 2:SUITE 502
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2226
Practice Address - Country:US
Practice Address - Phone:212-410-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1033782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RW05160910Medicare ID - Type Unspecified
C10807Medicare UPIN