Provider Demographics
NPI:1891010658
Name:WILLMS, JONATHAN RANDALL (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RANDALL
Last Name:WILLMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-381-0380
Mailing Address - Fax:520-836-1826
Practice Address - Street 1:580 N CAMINO MERCADO STE 8
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5757
Practice Address - Country:US
Practice Address - Phone:520-381-0380
Practice Address - Fax:520-836-1826
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ006349207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZFQ31815OtherMEDICARE
AZZ165308OtherMEDICARE
AZ031815OtherMEDICARE
AZ031916OtherMEDICARE
AZ006349OtherMEDICAL LICENSE
AZ901786Medicaid