Provider Demographics
NPI:1336118645
Name:WILLMON, BRIAN E (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:WILLMON
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 1:2200 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2011
Mailing Address - Country:US
Mailing Address - Phone:575-760-7134
Mailing Address - Fax:575-769-6464
Practice Address - Street 1:2000 W 21ST ST
Practice Address - Street 2:STE W-8
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-763-4479
Practice Address - Fax:505-763-6007
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37572Medicaid
NMNM301014Medicare PIN
NM$$$$$$$$$PMedicare PIN
C98268Medicare UPIN
NMNM301015Medicare PIN