Provider Demographics
NPI:1255334397
Name:DEBRABER, WILLARD PETER (DO)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:PETER
Last Name:DEBRABER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101551OtherPREFERRED CHOICES
MI3456139255OtherCOMM
MI1429OtherPH
MI103308Medicaid
MI1910582OtherUNITED HEALTHCARE
MI3456110440OtherBCR
MIP54169OtherBCN
MI2101067Medicaid
MI4098761OtherAETNA
MI382273611OtherCOMM
MI1429OtherPH
MI5613925Medicare ID - Type Unspecified
MI382273611OtherCOMM