MEDICARE: DR. WILLIE LEE DONALD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VM0101X	Maternal & Fetal Medicine Physician	01053966A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000195250	OTHER	IN	BCBS BMG MFM
2	000000857598	OTHER	IN	BCBS BMG E BLAIR WARNER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225026669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIE LEE DONALD M.D.

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 NAVARRE PL STE 4410
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1171
Country	:	US
Telephone Number	:	574-647-1650
Fax Number	:	574-647-1655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	11/30/2021

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