Provider Demographics
NPI:1699856534
Name:WILLINGMYRE, SANDRA LAURA (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LAURA
Last Name:WILLINGMYRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-5309
Mailing Address - Country:US
Mailing Address - Phone:520-298-0005
Mailing Address - Fax:520-207-0742
Practice Address - Street 1:2825 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5309
Practice Address - Country:US
Practice Address - Phone:520-298-0005
Practice Address - Fax:520-207-0742
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1209701Medicaid
NJ1209701Medicaid
NJ600574ABNMedicare ID - Type Unspecified