Provider Demographics
NPI:1902806243
Name:WILLETT, THOMAS RICE (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICE
Last Name:WILLETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:N6250 BUSSE DRIVE
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0429
Mailing Address - Country:US
Mailing Address - Phone:920-294-3444
Mailing Address - Fax:920-294-6660
Practice Address - Street 1:N6205 BUSSE RD
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-8500
Practice Address - Country:US
Practice Address - Phone:920-294-3444
Practice Address - Fax:920-294-6660
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2009-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI17659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391253020OtherTAX IDENTIFICATION NUMBER
WI30020000Medicaid
WI391253020013OtherBLUE CROSS/BLUE SHIELD
WIB57623Medicare UPIN
WI391253020013OtherBLUE CROSS/BLUE SHIELD