Provider Demographics
NPI:1235159096
Name:WILLIS, HALTER AND ASSOCIATES
Entity Type:Organization
Organization Name:WILLIS, HALTER AND ASSOCIATES
Other - Org Name:DIAGNOSTIC ASSOCIATES OF LUKFIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:936-634-7522
Mailing Address - Street 1:402 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3123
Mailing Address - Country:US
Mailing Address - Phone:936-634-7522
Mailing Address - Fax:936-639-4549
Practice Address - Street 1:402 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3123
Practice Address - Country:US
Practice Address - Phone:936-634-7522
Practice Address - Fax:936-639-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0080941103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083161201Medicaid
TX00J37AMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER