Provider Demographics
NPI:1356663413
Name:WILLARD P DEBRABER DO PC
Entity Type:Organization
Organization Name:WILLARD P DEBRABER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:DEBRABER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-773-3228
Mailing Address - Street 1:1761 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-2459
Mailing Address - Country:US
Mailing Address - Phone:231-773-3228
Mailing Address - Fax:231-773-3482
Practice Address - Street 1:1761 WELLS AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-2459
Practice Address - Country:US
Practice Address - Phone:231-773-3228
Practice Address - Fax:231-773-3482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006662208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1255334397OtherTYPE I NPI
MI2101067Medicaid
MI5611044OtherBLUE CROSS BLUE SHIELD
MI5611044OtherBLUE CROSS BLUE SHIELD