Provider Demographics
NPI:1447364658
Name:WILLENBORG, MICHAEL JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:WILLENBORG
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 1:5000 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2783
Mailing Address - Country:US
Mailing Address - Phone:972-420-1776
Mailing Address - Fax:972-436-6996
Practice Address - Street 1:5000 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-420-1776
Practice Address - Fax:972-436-6996
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3525207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194933101Medicaid
TXP00602966OtherRAILROAD MEDICARE
TX8W8230OtherBLUECROSS
TXP00602966OtherRAILROAD MEDICARE
TX194933101Medicaid