Provider Demographics
NPI:1174539555
Name:WILLATS, MARK L (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:WILLATS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 W 42ND ST
Mailing Address - Street 2:STE 2700
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4669
Mailing Address - Country:US
Mailing Address - Phone:308-632-3668
Mailing Address - Fax:308-635-1355
Practice Address - Street 1:2 W 42ND ST
Practice Address - Street 2:STE 2700
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4669
Practice Address - Country:US
Practice Address - Phone:308-632-3668
Practice Address - Fax:308-635-1355
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE261213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47081685307Medicaid
1201140001Medicare NSC
U61958Medicare UPIN
CI7016Medicare ID - Type UnspecifiedRAILROAD MEDICARE
098838Medicare ID - Type UnspecifiedGROUP #