Provider Demographics
NPI:1922333772
Name:VANNOSTRAND, WILLARD RANDOLPH III (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:RANDOLPH
Last Name:VANNOSTRAND
Suffix:III
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 1:1260 S CAMPBELL AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-0502
Mailing Address - Country:US
Mailing Address - Phone:520-407-5600
Mailing Address - Fax:520-407-5990
Practice Address - Street 1:1260 S CAMPBELL AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-0502
Practice Address - Country:US
Practice Address - Phone:520-407-5400
Practice Address - Fax:520-407-5990
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7028208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ01WCFBXA1OtherMEDICARE BILLING NO.
AZ01WCFBXA1OtherMEDICARE BILLING NO.