Provider Demographics
NPI:1134148562
Name:WILLMER, ADISA JOANNA (MD)
Entity type:Individual
Prefix:
First Name:ADISA
Middle Name:JOANNA
Last Name:WILLMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2902
Mailing Address - Country:US
Mailing Address - Phone:510-535-4400
Mailing Address - Fax:510-261-6438
Practice Address - Street 1:3124 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2902
Practice Address - Country:US
Practice Address - Phone:510-535-4400
Practice Address - Fax:510-261-6438
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067105207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49792Medicare UPIN