Provider Demographics
NPI:1023137684
Name:WILLES, EDRIC BROWNING (MD)
Entity type:Individual
Prefix:DR
First Name:EDRIC
Middle Name:BROWNING
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 1:674 SNOW CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3166
Mailing Address - Country:US
Mailing Address - Phone:760-872-2665
Mailing Address - Fax:760-872-2665
Practice Address - Street 1:150 PIONEER LANE
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3166
Practice Address - Country:US
Practice Address - Phone:760-872-2665
Practice Address - Fax:760-872-2665
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29373207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293730Medicaid
CA00G293730Medicaid
A89482Medicare UPIN