Provider Demographics
NPI:1598859746
Name:WILLIS, DEAN NORMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:NORMAN
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 1:50 FAIR HARBOUR PL
Mailing Address - Street 2:SUITE 2-C
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4731
Mailing Address - Country:US
Mailing Address - Phone:860-443-3147
Mailing Address - Fax:860-443-0087
Practice Address - Street 1:50 FAIR HARBOUR PL
Practice Address - Street 2:SUITE 2-C
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4731
Practice Address - Country:US
Practice Address - Phone:860-443-3147
Practice Address - Fax:860-443-0087
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22374208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001223742Medicaid
CT020011006Medicare PIN
CT020000463Medicare PIN
CT001223742Medicaid