Provider Demographics
NPI:1598162174
Name:DR. WILLARD'S FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:DR. WILLARD'S FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTICITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-699-3190
Mailing Address - Street 1:14100 E. ARAPAHOE RD.
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4048
Mailing Address - Country:US
Mailing Address - Phone:303-699-3190
Mailing Address - Fax:303-699-3189
Practice Address - Street 1:14100 E ARAPAHOE RD
Practice Address - Street 2:SUITE 170
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4028
Practice Address - Country:US
Practice Address - Phone:303-699-3190
Practice Address - Fax:303-699-3189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE95762Medicare UPIN