Provider Demographics
NPI:1962472464
Name:WILLEY, RICHARD MERLAND (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MERLAND
Last Name:WILLEY
Suffix:
Gender:M
Credentials:DO
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 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:19829 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4001
Practice Address - Country:US
Practice Address - Phone:602-246-2584
Practice Address - Fax:602-246-2566
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP000021402085R0202X
CA20A 95382085R0202X
SC9712085R0202X
AZ50402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ426571Medicaid
AZ426571Medicaid
AZZ130785Medicare PIN
AZZ130786Medicare PIN