Provider Demographics
NPI:1104998053
Name:WILLIS, MARY JANE HALL (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE HALL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34520 BOB WILSON DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-2098
Mailing Address - Country:US
Mailing Address - Phone:619-532-6896
Mailing Address - Fax:619-532-9184
Practice Address - Street 1:34520 BOB WILSON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-2098
Practice Address - Country:US
Practice Address - Phone:619-532-6896
Practice Address - Fax:619-532-9184
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75301207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A753010Medicaid
CAWA75301AMedicare ID - Type Unspecified
CA00A753010Medicaid