=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831138445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROGER C WILLETTE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1051 PINELOCH DR STE 600
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-990-9979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1051 PINELOCH DR STE 600
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-990-9979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G6771
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------