Provider Demographics
NPI:1679503163
Name:WILLIS, JOHNNIE SPRINGS (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:SPRINGS
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 1:685 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1165
Mailing Address - Country:US
Mailing Address - Phone:610-867-4151
Mailing Address - Fax:610-867-9129
Practice Address - Street 1:685 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1165
Practice Address - Country:US
Practice Address - Phone:610-867-4151
Practice Address - Fax:610-867-9129
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038968L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA672179Medicare ID - Type Unspecified
C28729Medicare UPIN