Provider Demographics
NPI:1881774743
Name:GREGORY WILLETT MD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GREGORY WILLETT MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-978-0884
Mailing Address - Street 1:3521 LOMITA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5041
Mailing Address - Country:US
Mailing Address - Phone:310-534-9131
Mailing Address - Fax:310-534-6132
Practice Address - Street 1:4477 W 118TH ST
Practice Address - Street 2:400
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2255
Practice Address - Country:US
Practice Address - Phone:310-978-0884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA228262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE98184Medicare UPIN
CAA22826Medicare ID - Type Unspecified
W21568Medicare PIN