Provider Demographics
NPI:1659471555
Name:INNOCENT, WILL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILL
Middle Name:
Last Name:INNOCENT
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:PO BOX 10176
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-0176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 W BUCKEYE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2647
Practice Address - Country:US
Practice Address - Phone:602-374-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92937207Q00000X
AZ32113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ849713Medicaid
FLI05494Medicare UPIN
FLFY843YMedicare PIN