Basic Information
| Provider Information | |||||||||
| NPI: | 1265409585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIG | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 815 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3201 W HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210404 | ||||||||
| FaxNumber: | 8173210486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2006 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | J2415 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | E-7535 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | E-7535 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | J2415 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 129430808 | 05 | TX | MEDICAID | 129430806 | 05 | TX | MEDICAID | 129430809 | 01 | TN | CSHCN | OTHER |