Provider Demographics
NPI:1831138445
Name:WILLETTE, ROGER C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:WILLETTE
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 1:1051 PINELOCH DR STE 600
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77062-2738
Mailing Address - Country:US
Mailing Address - Phone:281-990-9979
Mailing Address - Fax:
Practice Address - Street 1:1051 PINELOCH DR STE 600
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062-2738
Practice Address - Country:US
Practice Address - Phone:281-990-9979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6771174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097810801Medicaid
TX00D01FMedicare ID - Type Unspecified
TX097810801Medicaid
TX8F21797Medicare Oscar/Certification