Provider Demographics
NPI:1073584462
Name:WILLY, MARY E (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:WILLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:MCCRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:360 W PARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505
Mailing Address - Country:US
Mailing Address - Phone:970-609-7337
Mailing Address - Fax:970-233-9829
Practice Address - Street 1:360 W PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:970-609-7337
Practice Address - Fax:970-233-9829
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0045400208000000X
CODR0045400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC4117231Medicare ID - Type Unspecified
H94787Medicare UPIN
COCOA102073Medicare PIN