Provider Demographics
NPI:1629139076
Name:WILLIS, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WESCOTT DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4673
Mailing Address - Country:US
Mailing Address - Phone:908-788-4022
Mailing Address - Fax:908-788-4066
Practice Address - Street 1:1100 WESCOTT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4673
Practice Address - Country:US
Practice Address - Phone:908-788-4022
Practice Address - Fax:908-788-4066
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08845200207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0247138Medicaid
NJ800231ZDTPMedicare Oscar/Certification