Provider Demographics
NPI:1699871764
Name:WILLIS, OFELIA A (MD)
Entity type:Individual
Prefix:DR
First Name:OFELIA
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7251
Mailing Address - Country:US
Mailing Address - Phone:909-633-9992
Mailing Address - Fax:909-889-0820
Practice Address - Street 1:LOMA LINDA VA HOSPITAL
Practice Address - Street 2:11201 BENTON ST
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-0001
Practice Address - Country:US
Practice Address - Phone:909-583-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37625146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant