Provider Demographics
NPI:1396716874
Name:WOMACK, WILLIAM R (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:WOMACK
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 3297
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85271-3297
Mailing Address - Country:US
Mailing Address - Phone:000-000-0000
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:1525 N GRANITE REEF RD
Practice Address - Street 2:STE 7
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3998
Practice Address - Country:US
Practice Address - Phone:480-994-3432
Practice Address - Fax:480-994-5682
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ208951Medicaid
Z0000BBZPFMedicare PIN
AZ208951Medicaid