Provider Demographics
NPI:1629087663
Name:WILLMS, RICHARD KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KENNETH
Last Name:WILLMS
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 1:14565 CR 1113
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-9551
Mailing Address - Country:US
Mailing Address - Phone:903-595-3728
Mailing Address - Fax:903-595-0333
Practice Address - Street 1:14565 CR 1113
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-9551
Practice Address - Country:US
Practice Address - Phone:903-595-3728
Practice Address - Fax:903-595-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8691208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110137001Medicaid
00E069Medicare PIN
C23599Medicare UPIN
TX00E069Medicare UPIN
TXC23599Medicare Oscar/Certification