MEDICARE: DONALD WILLIS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A-822-85	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750347076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD WILLIS DO

Provider Business Mailing Address
First Line	:	1306 N GUADALUPE ST
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220-4676
Country	:	US
Telephone Number	:	505-887-8887
Fax Number	:	505-234-1362

Provider Business Practice Location Address
First Line	:	313 W COUNTRY CLUB RD
Second Line	:	SUITE # 9
City	:	ROSWELL
State	:	NM
Zip	:	88201-5804
Country	:	US
Telephone Number	:	505-624-1333
Fax Number	:	505-234-1362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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Directions to “ DONALD WILLIS DO” Practice Location

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