Provider Demographics
NPI:1750347076
Name:WILLIS, DONALD (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 N GUADALUPE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4676
Mailing Address - Country:US
Mailing Address - Phone:505-887-8887
Mailing Address - Fax:505-234-1362
Practice Address - Street 1:313 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE # 9
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5804
Practice Address - Country:US
Practice Address - Phone:505-624-1333
Practice Address - Fax:505-234-1362
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-822-85207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40790Medicaid
NME15925Medicare UPIN
NM40790Medicaid