Basic Information
| Provider Information | |||||||||
| NPI: | 1154344737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLERS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | ROGER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 JESSE JEWELL PKWY SE | ||||||||
| Address2: | STE B | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705327092 | ||||||||
| FaxNumber: | 7705360383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 017748 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1312061 | 01 | GA | CIGNA | OTHER | 52024086 | 01 | GA | BCBS | OTHER | 339676 | 01 | GA | WELLCARE | OTHER | 10062468 | 01 | GA | AMERIGROUP | OTHER | 000095235D | 05 | GA | MEDICAID | 000095235C | 05 | GA | MEDICAID | 0908757 | 01 | GA | UHC | OTHER |