Provider Demographics
NPI:1699905414
Name:WILLIG, AMY-JO
Entity type:Individual
Prefix:
First Name:AMY-JO
Middle Name:
Last Name:WILLIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BURKE LN
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3931
Mailing Address - Country:US
Mailing Address - Phone:516-921-8337
Mailing Address - Fax:516-921-1389
Practice Address - Street 1:4 BURKE LN
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3931
Practice Address - Country:US
Practice Address - Phone:516-921-8337
Practice Address - Fax:516-921-1389
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7090-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1791597Medicaid