Provider Demographics
NPI:1942275656
Name:WILLS, ANDREA D (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:D
Last Name:WILLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4206
Mailing Address - Country:US
Mailing Address - Phone:765-644-1225
Mailing Address - Fax:764-644-1447
Practice Address - Street 1:1931 BROWN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4206
Practice Address - Country:US
Practice Address - Phone:765-644-1225
Practice Address - Fax:765-644-1447
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200503250Medicaid
IN216590Medicare ID - Type Unspecified
IN200503250Medicaid