Provider Demographics
NPI:1730144551
Name:WILLIS, PETER L (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20 YORK STREET, CB-329
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-1734
Mailing Address - Fax:475-246-9106
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2922
Practice Address - Country:US
Practice Address - Phone:401-596-8990
Practice Address - Fax:401-865-2393
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD10903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine