Healthcare Provider Details

I. General information

NPI: 1902806243
Provider Name (Legal Business Name): THOMAS RICE WILLETT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6205 BUSSE RD
GREEN LAKE WI
54941-8500
US

IV. Provider business mailing address

PO BOX 429 N6250 BUSSE DRIVE
GREEN LAKE WI
54941-0429
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-3444
  • Fax: 920-294-6660
Mailing address:
  • Phone: 920-294-3444
  • Fax: 920-294-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17659
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: