Provider Demographics
NPI:1518909761
Name:WILLIS, PAUL WILLIAM JR (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:WILLIS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W. ARROW HWY., STE.106
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-592-9246
Mailing Address - Fax:909-592-9248
Practice Address - Street 1:1305 W. ARROW HWY., STE.106
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-592-9246
Practice Address - Fax:909-592-9248
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare ID - Type UnspecifiedPENDING MEDICARE CONTRACT