Provider Demographics
NPI:1205893864
Name:VAN WILLIGEN, DEBORAH A (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:VAN WILLIGEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:ANN
Other - Last Name:GAMERTSFELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1397A WEIMER ROAD
Mailing Address - Street 2:PO BOX DD
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-758-8883
Mailing Address - Fax:
Practice Address - Street 1:1397A WEIMER ROAD
Practice Address - Street 2:HOLY CROSS HOSPITAL
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-58207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00845Medicare UPIN