Healthcare Provider Details

I. General information

NPI: 1184641771
Provider Name (Legal Business Name): DONALD E WILLMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 KENMOOR AVENUE SE BRIGHTWAVE PAIN THERAPY
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

751 KENMOOR AVENUE SE BRIGHTWAVE PAIN THERAPY
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-608-5551
  • Fax: 616-608-5551
Mailing address:
  • Phone: 616-608-5551
  • Fax: 616-608-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS-3647
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25116-021
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34 002975
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101006554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: