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General NPI Number Information
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NPI Number | 1679734628
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Entity Type | Organization
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Legal Business Name | ROGER C WILLETTE MD; PA
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Dates
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Enumeration Date | 06/23/2008
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 1322 SPACE PARK DR STE B150
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City | HOUSTON
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State | TX
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Zip | 77058-3400
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Country | US
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Telephone | 281-333-1213
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Fax | 281-333-9573
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Provider Business Mailing Address
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Address Line | PO BOX 57805
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City | WEBSTER
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State | TX
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Zip | 77598-7805
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Country | US
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Telephone | 281-333-1213
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | CAREY KNEUPPER
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Credential |
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Telephone | 281-333-1213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G6771
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License Number State | TX
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