Provider Demographics
NPI:1558349001
Name:WILLI, MARTHA JOANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:JOANNE
Last Name:WILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARTHA
Other - Middle Name:JOANNE
Other - Last Name:WILLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1701 W GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-3531
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-680-7686
Practice Address - Street 1:1216 N MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1038
Practice Address - Country:US
Practice Address - Phone:309-674-4500
Practice Address - Fax:309-674-4500
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0306042307207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0306042037Medicaid
IL0306042037Medicaid
IL267270Medicare ID - Type Unspecified