Provider Demographics
NPI:1205169760
Name:WILLIS, JOEL S (DO)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 L ST NW STE 450
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1541
Mailing Address - Country:US
Mailing Address - Phone:216-476-7086
Mailing Address - Fax:216-476-7604
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:216-476-7086
Practice Address - Fax:202-741-2921
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-050910207Q00000X
DCDO034845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF3444OtherMEDICARE RR
IL370966854005Medicaid
IL370966854002Medicaid
IL141848Medicare Oscar/Certification
IL141840Medicare Oscar/Certification
IL208343001Medicare PIN