Provider Demographics
NPI:1891263489
Name:WILLIS, LYNDON TYRONE I
Entity Type:Individual
Prefix:MR
First Name:LYNDON
Middle Name:TYRONE
Last Name:WILLIS
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9206 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2361
Mailing Address - Country:US
Mailing Address - Phone:216-323-9262
Mailing Address - Fax:
Practice Address - Street 1:347 MIDWAY BLVD STE 210
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2496
Practice Address - Country:US
Practice Address - Phone:440-324-5555
Practice Address - Fax:440-324-5512
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program