MEDICARE: WILLARD P DEBRABER DO PC

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	208800000X	Urology Physician	5101006662	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1255334397	OTHER	MI	TYPE I NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5611044	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1356663413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLARD P DEBRABER DO PC

Provider Business Mailing Address
First Line	:	1761 WELLS AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-2459
Country	:	US
Telephone Number	:	231-773-3228
Fax Number	:	231-773-3482

Provider Business Practice Location Address
First Line	:	1761 WELLS AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-2459
Country	:	US
Telephone Number	:	231-773-3228
Fax Number	:	231-773-3482

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLARD PETER DEBRABER
Credential	:	D.O.
Telephone Number	:	231-773-3228

Provider Enumeration Date	:	02/17/2010
Last Update Date	:	05/18/2015

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