Basic Information
Provider Information | |||||||||
NPI: | 1841316254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLS | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | LEWIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 IRVING ST NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200102921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028771000 | ||||||||
FaxNumber: | 2028828434 | ||||||||
Practice Location | |||||||||
Address1: | 102 IRVING ST NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200102921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028771000 | ||||||||
FaxNumber: | 2028828434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 12/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD15363 | DC | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 5460-0022 | 01 |   | BS NCA 1500 | OTHER | 561071100 | 05 | MD |   | MEDICAID | 024027200 | 05 | DC |   | MEDICAID | 5421827003 | 01 |   | CIGNA | OTHER | DCA0015363 | 01 |   | BC NCA UB 92 | OTHER | 422791-01 | 01 |   | BS OF MARYLAND | OTHER | 4270331 | 01 |   | AETNA NON-HMO | OTHER | 250008028 | 01 |   | RAILROAD MEDICARE | OTHER | 110883 | 01 |   | KAISER | OTHER | 320227 | 01 |   | MAMSI | OTHER | 495032 | 01 |   | NCPPO | OTHER |