Provider Demographics
NPI:1255625422
Name:WILLERS, GARY PAUL II (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:PAUL
Last Name:WILLERS
Suffix:II
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 1:2500 N ESPLANADE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954
Mailing Address - Country:US
Mailing Address - Phone:361-275-3466
Mailing Address - Fax:361-275-3460
Practice Address - Street 1:2500 N ESPLANADE ST STE 102
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-4727
Practice Address - Country:US
Practice Address - Phone:361-275-3466
Practice Address - Fax:361-275-3460
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2778207Q00000X, 207Q00000X
TXP5906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX336088504Medicaid
TX482545YK7YOtherMEDICARE PTAN
TX336088503Medicaid