Provider Demographics
NPI:1134111834
Name:WILLOW VALLEY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:WILLOW VALLEY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-217-2464
Mailing Address - Street 1:8700 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-8519
Mailing Address - Country:US
Mailing Address - Phone:760-217-2464
Mailing Address - Fax:928-453-9207
Practice Address - Street 1:8700 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440-8519
Practice Address - Country:US
Practice Address - Phone:760-217-2464
Practice Address - Fax:928-453-9207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ205288-002Medicaid
CADI935AOtherMEDICARE PTAN
CAXPY055881Medicaid
AZ205288-01Medicaid
AZAZ0325100OtherAZ BCBS
AZ61413Medicare ID - Type UnspecifiedMEDICARE GROUP
080010348Medicare ID - Type UnspecifiedRR MEDICARE
AZ205288-01Medicaid
AZ205288-002Medicaid
CAXPY055881Medicaid