Provider Demographics
NPI:1407982291
Name:WILLY, MILDRED J (MD)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:J
Last Name:WILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5576 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9722
Mailing Address - Country:US
Mailing Address - Phone:989-686-3824
Mailing Address - Fax:
Practice Address - Street 1:800 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2551
Practice Address - Country:US
Practice Address - Phone:989-793-7220
Practice Address - Fax:989-793-7482
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078101A207Q00000X
MI4301068063207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4090679Medicaid
MI4090679Medicaid