Provider Demographics
NPI:1003023979
Name:WILLIE-MUSOMA, KATRINA L (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:WILLIE-MUSOMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6410
Mailing Address - Country:US
Mailing Address - Phone:817-557-5437
Mailing Address - Fax:817-539-0476
Practice Address - Street 1:2800 E BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6410
Practice Address - Country:US
Practice Address - Phone:817-557-5437
Practice Address - Fax:817-539-0476
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9742208000000X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
00R86COtherMEDICARE GROUP NPI
TX084933301OtherTMHP/MEDICAID GROUP TPI
TX195476005Medicaid
TXTXB135922Medicare PIN