Provider Demographics
NPI:1407142961
Name:SIU, WILLIE O (MD, DPHIL)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:O
Last Name:SIU
Suffix:
Gender:M
Credentials:MD, DPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 1G
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5220
Mailing Address - Country:US
Mailing Address - Phone:617-299-6794
Mailing Address - Fax:
Practice Address - Street 1:1105 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 1G
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5220
Practice Address - Country:US
Practice Address - Phone:617-299-6794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2589782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry