Provider Demographics
NPI:1154412187
Name:WILLIS, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WILLIS
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 1446
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07962-1446
Mailing Address - Country:US
Mailing Address - Phone:973-538-2334
Mailing Address - Fax:973-829-9174
Practice Address - Street 1:160 E HANOVER AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-3150
Practice Address - Country:US
Practice Address - Phone:973-538-2334
Practice Address - Fax:973-829-9174
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07774400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0073822Medicaid
NJ0514943OtherAETNA HMO#
NJ0796671000OtherAMERIHEALTH #
NJG20272OtherAMERIHEALTH ADM #
NJIS454OtherOXFORD #
NJ0073822OtherAETNA PPO#
NJ5713656OtherGHI PPO #
NJG20272OtherAMERIHEALTH ADM #
NJ5713656OtherGHI PPO #