Healthcare Provider Details

I. General information

NPI: 1629087663
Provider Name (Legal Business Name): RICHARD KENNETH WILLMS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14565 CR 1113
TYLER TX
75703-9551
US

IV. Provider business mailing address

14565 CR 1113
TYLER TX
75703-9551
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-3728
  • Fax: 903-595-0333
Mailing address:
  • Phone: 903-595-3728
  • Fax: 903-595-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberC8691
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberC8691
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: