Provider Demographics
NPI:1063525715
Name:WILLS, MARK GORTON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GORTON
Last Name:WILLS
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:PO BOX 10609
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-0609
Mailing Address - Country:US
Mailing Address - Phone:877-818-6100
Mailing Address - Fax:
Practice Address - Street 1:347 ANDRIEUX STREET
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6811
Practice Address - Country:US
Practice Address - Phone:707-935-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63295207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G632950Medicaid
CAD44647Medicare UPIN
CA00G632957Medicare PIN
CA00G632955Medicare PIN