Healthcare Provider Details

I. General information

NPI: 1093955189
Provider Name (Legal Business Name): DONALD J WILLIS D.O. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W COUNTRY CLUB RD SUITE 9
ROSWELL NM
88201-5804
US

IV. Provider business mailing address

313 W COUNTRY CLUB RD SUITE 9
ROSWELL NM
88201-5804
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-2095
  • Fax: 575-627-5721
Mailing address:
  • Phone: 575-624-1333
  • Fax: 575-627-5721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA-822-85
License Number StateNM

VIII. Authorized Official

Name: DR. DONALD J WILLIS
Title or Position: D.O.
Credential:
Phone: 575-624-1333