Provider Demographics
NPI:1093725384
Name:MAGDAMO, WILLIE B JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:B
Last Name:MAGDAMO
Suffix:JR
Gender:M
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:940 HESTERS CROSSING RD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-8018
Practice Address - Country:US
Practice Address - Phone:512-244-9024
Practice Address - Fax:512-218-3704
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081798207Q00000X
NC2008-00972207Q00000X
TXP0993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4920898Medicaid
MI4920913Medicaid
TX300697501Medicaid
TX300697502Medicaid
MI4920904Medicaid
NC5909872Medicaid
NC2022575JMedicare PIN
NC2022575Medicare PIN
MII63604Medicare UPIN
MI4920898Medicaid
TXP01137352Medicare PIN
NC2022575FMedicare PIN
NC2022575EMedicare PIN
NC2022575DMedicare PIN
NC5909872Medicaid
NC2022575MMedicare PIN
TXTXB152107Medicare PIN
NC2022575AMedicare PIN
NC2022575KMedicare PIN
NC2022575GMedicare PIN
NC2022575CMedicare PIN
NC2022575BMedicare PIN
TX300697502Medicaid