Provider Demographics
NPI:1104998863
Name:WILL, TIA D (MD)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:D
Last Name:WILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:DIANE
Other - Last Name:WILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:1955 COWELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6325
Practice Address - Country:US
Practice Address - Phone:916-757-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53412207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G534120Medicaid
E81993Medicare UPIN
00G534120Medicare ID - Type Unspecified