Provider Demographics
NPI:1194719146
Name:WILLER, JUSTIN AARON (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:AARON
Last Name:WILLER
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 1:705 ARBUCKLE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2703
Mailing Address - Country:US
Mailing Address - Phone:718-859-8920
Mailing Address - Fax:718-859-7438
Practice Address - Street 1:741 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1113
Practice Address - Country:US
Practice Address - Phone:718-859-8920
Practice Address - Fax:718-859-7438
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1748362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01085625Medicaid
NY24E841Medicare ID - Type Unspecified
NY01085625Medicaid