Provider Demographics
NPI:1225026669
Name:DONALD, WILLIE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:LEE
Last Name:DONALD
Suffix:
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 4410
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-1650
Practice Address - Fax:574-647-1655
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053966A207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000195250OtherBCBS BMG MFM
IN000000857598OtherBCBS BMG E BLAIR WARNER
IN200318520Medicaid
IN200318520Medicaid
IN162520011Medicare PIN