Provider Demographics
NPI:1821183542
Name:WILLES, STUART R (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:R
Last Name:WILLES
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 1:501 FAIRMOUNT AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286
Mailing Address - Country:US
Mailing Address - Phone:410-494-7921
Mailing Address - Fax:410-902-8247
Practice Address - Street 1:9103 FRANKLIN SQUARE DR
Practice Address - Street 2:300
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3900
Practice Address - Country:US
Practice Address - Phone:410-682-5282
Practice Address - Fax:410-682-5286
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0036663207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
345806OtherMAMSI
290008363OtherRAILROAD MEDICARE
4800203OtherUNITED HEALTHCARE MCO
MD42428624 420AOtherBLUE SHIELD
MD0009 E554OtherBLUE CHOICE/FEP
1427796OtherUNITED HEALTHCARE
MD533281800Medicaid
MDK53114BRMedicare ID - Type Unspecified
MD533281800Medicaid