Provider Demographics
NPI:1649218975
Name:WILLIS, ELLIOTT HERSCHEL (DO)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:HERSCHEL
Last Name:WILLIS
Suffix:
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 1:301 OXFORD VALLEY RD
Mailing Address - Street 2:SUITE 905A
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7706
Mailing Address - Country:US
Mailing Address - Phone:215-321-9896
Mailing Address - Fax:215-321-4369
Practice Address - Street 1:301 OXFORD VALLEY RD
Practice Address - Street 2:SUITE 905A
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7706
Practice Address - Country:US
Practice Address - Phone:215-321-9896
Practice Address - Fax:215-321-4369
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2013-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003457L207Q00000X
NJ25MB03196100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0022645000OtherKEYSTONE IBC
PA35651OS003457LOtherHEALTH PARTNERS
PA0070048520002Medicaid
PA6296514OtherAETNA HMO
PA105263OtherHIGHMARK BLUE SHIELD
080084616OtherPALMETTO GBA RAILROAD MED
PA30079314OtherKEYSTONE MERCY
PA105263Medicare ID - Type Unspecified
PA30079314OtherKEYSTONE MERCY
PA0022645000OtherKEYSTONE IBC